PURPOSE: This rule prescribes a standard means test as required by section 630.210, RSMo to determine amounts to be charged for services provided or procured by the Department of Mental Health.

Editor’s Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or expensive. The entire text of the material referencedhas been filed with the secretary of state. This material may be found at the Office of the Secretary of State or at the headquarters of the agency and is available to any interested person at a cost established by law.

1. (1) Definitions. The terms defined in section 630.005, RSMo are incorporated by reference as though set out in this rule. The following other terms used in this rule, unless the text clearly requires otherwise, shall mean:

   1. (A) Adjusted gross monthly income—the income remaining after allowable deductions permitted by this rule;
   2. (B) Community support services—for the Division of Mental Retardation and Developmental Disabilities (MRDD), this means all Purchase of Service (POS) services, case management services for clients residing in Community Placement Program

2. (CPP) facilities and in their natural homes, Choices for Families services and all voucher services; for the Division of Comprehensive Psychiatric Services (CPS), this means Family Preservation services, Intensive Case Management services for children and adults, POS Community Psychiatric Rehabilitation Program (CPRP) services, Supported Housing Voucher Program or Housing and Urban Development (HUD) Housing Voucher Program services, and Intergrated Employment Support services; for the Division of Alcohol and Drug Abuse (ADA), this applies to drug-free counseling services provided to clients participating in a methadone maintenance program who have become drug-free;

   1. (C) Early intervention services—developmental services provided by qualified personnel to meet infant’s or toddler’s developmental needs in one (1) or more of the following areas: physical development, cognitive development, language and speech development, psychosocial development or self-help skills. Early intervention services must be provided in conformity with an individualized family service plan. Early intervention services may include, but are not limited to:

      1. 1. Family training, counseling and

home visits;

1. 2. Special instructions;
2. 3. Speech pathology and audiology;
3. 4. Occupational therapy;
4. 5. Physical therapy;
5. 6. Transportation;
6. 7. Psychological services;
7. 8. Social work;
8. 9. Case management services;
9. 10. Nursing services; 9 CSR 10-31

1 1 . Nutrition services; 12. Medical services for diagnostic or

evaluation purposes;

1. 13. Early identification, screening and

assessment services; and

1. 14. Health services which enable infants

or toddlers to benefit from other early intervention services;

1. (D) Financially responsible person—the individual who is obligated by law or this rule to pay charges for services;
2. (E) Gross monthly income (earned and unearned)—the total monthly income from all sources before payroll deductions, other withholdings and expenses incurred in earning the income. Examples would include salaries and wages, dividends, annuities, interest, rents, pensions, disability and survivor benefits, Workers’ Compensation, unemployment compensation, maintenance and child support payments, bonuses, tips and gratuities, income from business or profession and any other taxable and nontaxable income;
3. (F) Household size—the number of persons dependent upon the income of the financially responsible person including the person (recipient) receiving services, except for a blended family situation. Dependency for family members, other than the recipient, must meet the dependency test in the federal Internal Revenue Code;

4. (G) Long-term care—continuous residential care (excluding supportive housing) which meets any of the following conditions:

   1. 1. Admission to a habilitation center;
   2. 2. Admission to a community placement

facility;

1. 3. A statement signed by a physician or

a qualified mental health professional that the care is for an indeterminate period; or

1. 4. The care has been provided for at

least twenty-four (24) months without any documentation in the recipient’s individualized treatment, habilitation or rehabilitation plan indicating discharge is imminent (within ninety (90) days);

1. (H) Monthly rate—the amount determined by application of the sliding fee scale to be charged for services provided in a month;
2. (I) Provider—a public or private agency offering services to individuals approved for Department of Mental Health (DMH)-funded services;
3. (J) Recipient-client, patient or resident— the person receiving services;
4. (K) Representative payee—guardian, trustee, conservator or other fiduciary appointed to receive a beneficiary’s benefits (for example, Social Security, Railroad Retirement);
5. (L) Sliding fee scale—a table for determining the monthly rate to be charged to a financially responsible person for services; and
6. (M) Unearned income—income that is not derived from employment. Examples would include maintenance and child support monies, interests, pensions, unemployment benefits, Workers’ Compensation and benefits from the Social Security Administration, Railroad Retirement Board, Civil Service Commission, Veterans Administration and other similar types of income.

1. (2) Charges Not to Exceed Costs. The charges determined by the application of this rule shall not exceed costs. For providers operated by the department, the costs are determined annually as required by section 630.210, RSMo. For other providers, the costs are authorized by contract with the department. If more than one (1) source of reimbursement is being charged, then collectively the charges shall not exceed costs.

2. (3) Community Support Incentives (POS). The following financial incentives shall be provided to clients and families receiving less costly community support services:

   1. (A) Clients or their financially responsible parties shall be assessed at a rate of one-fourth (1/4) their monthly ability to pay, for community support services which are received by the client, except for the case management services specified in subsection (3)(B). Insurance companies and other third-party payers shall be billed at actual cost for all community support services, including the case management services specified in subsection (3)(B); and
   2. (B) For case management services reimbursed by the Division of Mental Retardation and Developmental Disabilities and intensive case management services reimbursed by the Division of Comprehensive Psychiatric Services, only clients or their financially responsible parties with annual adjusted gross incomes exceeding one hundred thousand dollars ($100,000) shall be assessed a charge, and the charge shall be the lesser of actual cost or one-fourth (1/4) their monthly ability to pay.
3. (4) Health Insurance. The provider shall apply to the costs incurred for providing services to the recipient the benefits received or available on behalf of or to the recipient from private and public health insurance, health services corporation and health maintenance organization plans, policies and contracts including individual, company, fraternal, group, Medicare, Medicaid and similar plans to the extent and limits of the coverage for the recipient. If a federal program requires the department to accept federal reimbursement as full payment as a condition of participation in the program for certain services, the provider shall not charge the financially responsible person for the services except the federally permitted deductibles or coinsurances.

4. (5) Financial Responsibility. As set out in section 630.205, RSMo, the following are jointly and severally liable to pay under this rule for services rendered to a recipient:

   1. (A) The recipient;
   2. (B) The recipient’s estate only to the extent of the assets in the estate, if the recipient has a conservator or is deceased;
   3. (C) The recipient’s spouse unless otherwise provided for in a separation agreement or dissolution order approved by a court of competent jurisdiction;
   4. (D) The recipient’s natural parents’ ability to pay is based separately on their own income with each claiming the children from that marriage as dependents. All child support, even if it is for other children that were a result of that marriage that are not our clients, will be considered in total income;
   5. (E) Any fiduciary, such as a trustee, only to the extent of the assets the fiduciary is holding on behalf of or for the recipient, which assets may be used according to law; except for any assets held in the Missouri Family Trust Fund on behalf of or for the recipient;
   6. (F) Any representative payee to the extent of the benefits and assets under the law governing and permitting payment of benefits and assets for the recipient;

   7. (G) The recipient’s parents if the recipient is a minor (under age eighteen (18)), except the following:

      1. 1. The parents of a minor recipient who

has been emancipated;

1. 2. The parents of a minor recipient if the

parents have relinquished parental responsibility through legal adoption or have had parental rights terminated by an action of a juvenile court;

1. 3. The parents of a recipient age three to

eighteen (3—18), a recipient age three to twenty-one (3—21) or the spouse or estate of a recipient age three to twenty-one (3—21) are not liable for the cost of education, special education or related services. The parents of a recipient age birth to three (0—3) are not liable for the cost of prevention and early intervention services provided through P.L. 102-1 1 9 Part H First Steps. The term special education, as used in this rule, is defined in 34 CFR Section 300a.14. The term related services, as used in this rule, is defined in 34 CFR 300a.13;

1. 4. The adoptive parents of a minor

recipient who had been, before the adoption, court committed to the legal custody of the department, the Department of Social Services or a charitable organization; and

1. 5. Stepparents’ income;
2. (H) If two (2) or more members of a household receive services in the same month, the provider shall charge no more than the amounts determined by application of the sliding fee scale for one (1) recipient. Before this shall apply, the financially responsible person shall notify the provider when services are provided to more than one

1. (1) member of the household in the same month;

   1. (I) If the recipient is eligible for Medicaid (under any state entitlement program), Supplemental Security Income (SSI), General Relief (GR) or Food Stamps, the Standard Means Test (SMT) is not required to be implemented, with the exceptions that are found in other parts of this rule. Documentation of the eligibility must be placed in the financial file in lieu of an SMT;
   2. (J) If the recipient is eligible for Title IV- A, the SMT will not need to be implemented. Documentation of eligibility must be placed in the financial file in lieu of an SMT;
   3. (K) If it appears from the application of the SMT that the recipient could be assessed under more than one (1) client identifier, the formula which requires the least amount of client pay will be used; and
   4. (L) The department shall consider noncustodial parents court orders regarding support payments and medical coverage obligations.
2. (6) Charges for Nonresidents. If a recipient of any age is not domiciled in this state, as defined in 9 CSR 10-31.016, then those responsible to pay, the parents, school district, special district or state department or agency of the recipient’s domicile, under this rule are liable to pay the full cost of the services.

3. (7) Sliding Fee Scale. The scale determines the monthly rate to be charged to a financially responsible person for services. The scale was developed using one hundred fifty percent (150%) of the federal poverty guidelines for the year 1996 and income withholding tables for federal and state taxes. The scale shall be updated annually when changes have occurred in the federal poverty guidelines or the tax withholding tables. The adjusted gross monthly income on the sliding fee scale is determined by deducting the following expenses from gross income:

   1. (A) Business expenses and expenses incurred on income-producing property when the income is included in gross income under this rule and the expenses were deducted on the federal income tax return;
   2. (B) Business expenses which have no history and are now being claimed will be based on federal tax guidelines; if a review finds business expenses were invalid, then the rate will be adjusted to their ability to pay, retroactively;
   3. (C) Medical expenses deducted by the taxpayer (financially responsible person) on the most recent filed tax year that exceed the federal percentage rate allowable of the federal adjusted gross income in (1996) or medical expenses that exceed the federal percentage and cannot be claimed on the federal tax return due to inability to itemize deductions, proof of payment must be presented;
   4. (D) Medical expenses, anticipated or unanticipated, that will be scheduled as a monthly payment. Documentation must be presented that the payments have been or are being made. If a review finds that payments were not or are not being made, then the rate will be adjusted to their actual ability to pay, retroactively; and
   5. (E) Child support paid by a parent, whether the parent can claim the child as a dependent or not, shall be a deduction to income. Documentation must be provided that payments are being made.

4. (8) Charges for Long-Term Care. The charges shall be determined under this section when the recipient requires long-term care.

   1. (A) If the recipient is with his/her spouse or dependents, the provider shall charge the recipient, his/her estate, fiduciary or representative payee as follows: If the recipient is with his/her spouse or dependents, all unearned income should be treated as earned income and assessed according to the sliding fee scale, except in those cases where the spouses are estranged.
   2. (B) If the recipient in a residential care or inpatient facility purchased or operated by DMH is without spouse or dependents, then the provider shall consider all of a recipient’s real and personal property when the provider has obtained and filed an annual statement from a licensed physician or a qualified mental health professional indicating that the recipient requires full-time residential services or, if the recipient has been in full-time residential services, twenty-four (24) or more continuous months previously. The provider shall charge all costs until the recipient’s estate is reduced to the allowable amount for Medicaid eligibility, except cash and securities shall not exceed ninety-five percent (95%) of the Medicaid limit on cash and securities. The provider (DMH-operated or purchased facility) shall apply all unearned income to the cost of services, except that the provider shall make an allowance of thirty dollars ($30) or more per month for personal spending as specified in the recipient’s individualized treatment, habilitation or rehabilitation plan. If the representative payee is the conservator, then the court-ordered costs shall be a reduction in the amount assessed upon the recipient’s benefits.
   3. (C) Subsections (8)(A) and (B) of this rule may be waived whenever the release of the recipient is imminent (within ninety (90) days), the unmet needs of the recipient have been documented and the recipient’s existing funds are inadequate to pay the costs of the needs documented in the recipient’s individualized habilitation, rehabilitation or treatment plan.
5. (9) Working Clients. If the recipient is a working client and is without a spouse, dependents, or both, the provider shall apply to costs of services forty percent (40%) of all net earned income exceeding one hundred dollars ($100) per month, except in cases where DMH is not paying room and board costs. In these cases, the sliding fee scale shall be applied.
6. (10) Documentation Requirements. Financially responsible persons shall furnish the provider written statements of their income (for example, most recent year’s filed complete federal tax return) or other supporting documentation requested by the provider for income verification. If the provider applies the long-term care provisions under this rule, then the provider shall obtain a statement of the recipient’s personal and real assets and other supporting documentation. Documentation must be provided for any deductions to gross income.
7. (11) Failure to Comply. The provider shall have the recipient or financially responsible person apply for benefits and entitlements described in this rule if it appears the recipient is eligible. The provider may charge the 9 CSR 10-31

financially responsible person all costs of providing or procuring the services when the recipient or financially responsible person— (A) Deliberately fails to divulge financial resources upon request of the provider; (B) Fails to apply or permit the provider to apply for benefits; or (C) Fails to assign benefits.

1. (12) Failure to Pay. The provider may take action to collect any unpaid amounts charged based on the sliding fee scale or the full cost based on the failure to comply. These actions may include, but are not limited to, Missouri State Income Tax Intercept and any further action allowable under state and federal law.
2. (13) Voluntary Payments. The provider may accept voluntary payments from individuals not legally obligated to pay and payments made in addition to the amounts determined by application of this rule. Providers operated by the department shall receive gifts, donations, devises or bequests as set out in section 630.330, RSMo. For services to clients, vendors or department-operated providers may set a minimal charge for services to clients which may exceed the monthly charge applicable under this rule. The charge shall not exceed five dollars ($5) per visit and shall be an offset against any charges determined as otherwise applicable under this rule, per program, per provider. If one (1) client is assessed a minimal charge, all clients in that program must be assessed the same minimal charge. The provider can determine that an urgent need for immediate services overrides any inability or refusal to pay.

3. (14) Test Application Procedures. The director delegates his/her authority to complete the SMT to any provider operated by the department. Other providers (for example, nonstate community mental health centers or substance abuse programs) which serve recipients directly without having them go through department case management shall apply the test if the providers agree to do so under the terms of contracts with the department.

   1. (A) The provider shall apply the SMT contained in this rule at admission, annually after admission if the recipient is still receiving services, upon request from the recipient or responsible party, or by the initiative of the provider or the department director due to any significant change in financial status.
   2. (B) The provider shall apply the test in this rule on all recipients as of February 26, 1993.
   3. (C) Upon request for review, the provider shall change the monthly rate, if warranted, effective to the first day of the month of the date of request.
   4. (D) As other substantial changes occur in income or asset status, the provider shall reapply the test and the changes shall be effective as of the first day of the month following the date of the reapplication of the test. If inaccurate or fraudulent information was provided for determining charges, or if the recipient is entitled to retroactive benefits, the provider shall retroactively change the amount charged.

4. (15) Appeal Procedures. The application of the SMT may be appealed by the financially responsible person to the chief administrative officer of the provider and then the department director as follows:

   1. (A) The chief administrative officer of the provider shall review upon appeal the application of the test as to the verification of financial resources, the determination of charges and issue a decision to the financially responsible person;
   2. (B) The decision of the chief administrative officer of the provider may be appealed to the department director within fifteen (15) days of the receipt of the decision. The director will review appeals only if the recipient or responsible party alleges the incorrect application of the test. Upon completion of the review, the director shall issue a decision which may alter application of the test;
   3. (C) As set out in section 630.210, RSMo, the decision of the director may be reviewed in the circuit court of Cole County or the circuit court in the county where the financially responsible person legally obligated to pay resides according to the procedure set out in Chapter 536, RSMo; and
   4. (D) Pending the decision upon appeal by the provider’s chief administrative officer, the decision of the department director, if appealed, or decision of a court of competent jurisdiction, if judicially reviewed, whichever is later, the department shall hold the provider harmless and shall pay disputed amounts to the provider, if necessary, to continue services to the recipient. If the financially responsible person is deemed obligated to pay any of the disputed amounts after the appeal is completed, then the financially responsible person shall pay the amounts to the provider as an offset to the department’s future support or to the department if no future department support is to be provided.

5. (16) Probation and Parole Clients. For services provided under terms and conditions of probation and parole, the provider may determine charges related to income and consistent with the treatment and rehabilitation goals of the terms and conditions of probation and parole as approved in writing by the department and the supervising court.

   Auth: sections 630.050 and 630.210, RSMo (1994).* Original rule filed May 12, 1981, effective Jan. 1, 1982. Emergency amendment filed March 19, 1982, effective April 1, 1982, expired July 11, 1982. Amended: Filed April 14, 1982, effective July 11, 1982. Emergency amendment filed Dec. 20, 1982, effective Jan. 1, 1983, expired April 1, 1983. Emergency amendment filed June 20, 1983, effective July 1, 1983, expired Nov. 1, 1983. Amended: Filed June 20, 1983, effective Nov. 1, 1983. Emergency amendment filed Sept. 13, 1983, effective Oct. 1, 1983, expired Jan. 1, 1984. Amended: Filed Sept. 13, 1983, effective Jan. 1, 1984. Amended: Filed Oct. 11, 1984, effective Jan. 14, 1985. Amended: Filed Aug. 15, 1985, effective Nov. 11, 1985. Emergency amendment filed June 17, 1986, effective June 27, 1986, expired Oct. 15, 1986. Amended: Filed July 14, 1986, effective Nov. 28, 1986. Emergency amendment filed Dec. 20, 1990, effective Dec. 30, 1990, expired April 28, 1991. Amended: Filed Dec. 21, 1990, effective April 29, 1991. Emergency amendment filed May 21, 1991, effective July 1, 1991, expired Oct. 28, 1991. Amended: Filed Feb. 15, 1991, effective Aug. 30, 1991. Emergency rule filed Oct. 13, 1992, effective Oct. 23, 1992, expired Feb. 19, 1993. Emergency amendment filed Oct. 23, 1992, effective Nov. 2, 1992, expired Feb. 19, 1993. Rescinded and readopted: Filed May 15, 1992, effective Feb. 26, 1993. Emergency rule filed Feb. 10, 1993, effective Feb. 20, 1993, expired June 19, 1993. Amended: Filed Nov. 4, 1992, effective May 6, 1993. Amended: Filed July 17, 1995, effective Jan. 30, 1996.

   *Original authority: 630.050, RSMo (1980) and 630.210, RSMo (1980), amended 1981, 1982. Adjusted Gross

Monthly Income To and From Including 913 987 988 1062 1063 1137 1138 1212 1213 1287 1288 1362 1363 1437 1438 1512 1513 1587 1588 1662 1663 1737 1738 1812 1813 1887 1888 1962 1963 2037 2038 2112 2113 2187 2188 2262 2263 2337 2338 2412 2413 2487 2488 2562 2563 2637 2638 2712 2713 2787 2788 2862 2863 2937 2938 3012 3013 3087 3088 3162 3163 3237 3238 3312 3313 3387 3388 3462 3463 3537 3538 3612 3613 3687 3688 3762 3763 3837 3838 3912 3913 3987 3988 4062 4063 4137 4138 4212 4213 4287 4288 4362 4363 4437 4438 4512 4513 4587 4588 4662 4663 4737 4738 4812 4813 4887 Missouri Department of Mental Health

1 2

70 13 84 26 97 39 111 53 124 66 137 80 151 93 164 106 177 120 191 133 210 146 221 160 232 173 243 187 254 200 265 213 276 227 287 240 298 253 309 266 320 280 331 293 342 307 353 320 364 334 374 347 385 360 396 374 407 388 418 401 428 414 439 427 450 440 461 454 471 467 482 480 493 492 504 503 514 514 525 525 536 536 547 546 557 557 568 568 578 579 589 589 599 600 609 611 Sliding Fee Scale—Monthly Rate

Household Size

3 4

63 6 76 19 89 32 103 46 116 59 130 73 143 86 156 99 170 113 183 126 196 139 209 153 223 166 236 179 250 193 263 206 277 220 290 233 303 246 317 260 331 274 344 287 357 300 370 313 383 326 397 340 410 353 423 366 436 379 449 392 462 405 474 419 485 432 496 445 507 456 517 467 528 478 539 489 550 499 560 510 5 6

69 12 82 25 95 38 109 52 122 65 135 78 149 92 162 105 175 118 189 132 203 146 216 159 229 172 242 185 256 199 269 212 282 225 295 238 308 251 322 265 335 278 348 291 361 304 374 317 388 331 401 344 414 357 427 370 438 383 449 396 459 409 9 CSR 10-31

7 8

62 5 75 18 89 32 102 46 116 59 129 72 142 85 155 98 168 112 181 125 195 138 208 151 221 164 234 177 247 191 261 204 274 217 287 230 300 243 313 257 327 270 340 283 353 296 9 10

68 12 81 25 94 38 107 51 120 64 134 78 147 91 160 104 173 117 186 130 200 144 213 157 226 170 239 183 Adjusted Gross Monthly Income To and From Including 4888 4962 4963 5037 5038 5112 5113 5187 5188 5262 5263 5337 5338 5412 5413 5487 5488 5562 5563 5637 5638 5712 5713 5787 5788 5862 5863 5937 5938 6012 6013 6087 6088 6162 6163 6237 6238 6312 6313 6387 6388 6462 6463 6537 6538 6612 6613 6687 6688 6762 6763 6837 6838 6912 6913 6987 6988 7062 7063 7137 7138 7212 7213 7287 7288 7362 7363 7437 7438 7512 7513 7587 7588 7662 7663 7737 7738 7812 7813 7887 7888 7962 7963 8037 8038 8112 8113 8187 8188 8262 8263 8337 8338 8412 8413 8487 8488 8562 8563 8637 8638 8712 8713 8787 8788 8862 8863 8937 1 2 619 622 629 632 639 643 650 654 662 665 673 675 684 686 696 697 707 708 719 718 730 729 741 740 753 751 764 761 775 772 787 783 798 794 809 804 821 815 832 826 843 837 855 847 866 858 877 869 889 880 900 890 911 901 923 912 934 923 946 933 957 944 968 955 980 966 991 976 1002 987 1014 998 1025 1009 1036 1019 1048 1029 1059 1039 1070 1049 1082 1060 1093 1070 1104 1080 1116 1090 1127 1100 1138 1110 1150 1121 1161 1131 1173 1141 1184 1151 1195 1161 1207 1172 1218 1182 Household Size

3 4 571 521 582 532 593 542 603 553 614 564 625 575 636 585 646 596 657 607 668 618 679 628 690 639 700 650 711 661 722 671 733 682 743 693 754 704 765 714 776 725 786 736 797 747 808 757 819 768 829 779 840 790 851 801 862 811 872 822 883 833 894 844 905 854 915 865 926 876 937 887 948 897 958 908 969 919 980 930 990 940 1001 951 1011 962 1021 972 1031 983

1042 993 1052 1003 1062 1013 1072 1023 1082 1034 1093 1044 1103 1054 1113 1064 1123 1074 1133 1085 5 6 470 420 481 431 492 441 503 452 513 463 524 474 535 484 546 495 556 506 567 517 578 527 589 538 599 549 610 560 621 570 632 581 642 592 653 603 664 613 675 624 685 635 696 646 707 657 718 667 728 678 739 689 750 700 761 710 771 721 782 732 793 743 804 753 814 764 825 775 836 786 847 796 857 807 868 818 879 829 890 839 900 850 911 861 922 872 933 882 943 893 954 904 964 915 974 925 984 936 995 946 1005 956 1015 966 1025 976 1035 987 7 8 366 309 379 323 391 336 402 349 413 362 424 374 434 384 445 395 456 406 467 417 477 427 488 438 499 449 510 460 520 471 531 481 542 492 553 503 564 514 574 524 585 535 596 546 607 557 617 567 628 578 639 589 650 600 660 610 671 621 682 632 693 643 703 653 714 664 725 675 736 686 746 696 757 707 768 718 779 729 789 739 800 750 811 761 822 772 832 782 843 793 854 804 865 815 875 825 886 836 897 847 908 858 918 868 928 879 938 890 9 10 252 196 266 210 279 223 292 236 305 249 318 262 331 275 345 289 356 302 367 315 377 328 388 339 399 350 410 360 420 371 431 382 442 393 453 403 463 414 474 425 485 436 496 446 506 457 517 468 528 479 539 489 549 500 560 511 571 522 582 533 592 543 603 554 614 565 625 576 635 586 646 597 657 608 668 619 678 629 689 640 700 651 711 662 721 672 732 683 743 694 754 705 764 715 775 726 786 737 797 748 807 758 818 769 829 780 840 791 Adjusted Gross Monthly Income To and From Including 8938 9012 9013 9087 9088 9162 9163 9237 9238 9312 9313 9387 9388 9462 9463 9537 9538 9612 9613 9687 9688 9762 9763 9837 9838 9912 9913 9987 9988 10062 10063 10137 10138 10212 10213 10287 10288 10362 10363 10437 10438 10512 10513 10587 10588 10662 10663 10737 10738 10812 10813 10887 10888 10962 10963 11037 11038 11112 11113 11187 11188 11262 11263 11337 11338 11412 11413 11487 11488 11562 11563 11637 11638 11712 11713 11787 11788 11862 11863 11937 11938 12012 12013 12087 12088 12162 12163 12237 12238 12312 12313 12387 12388 12462 12463 12537 12538 12612 12613 12687 12688 12762 12763 12837 12838 12912 12913 12987 12988 13062 1 2 1229 1192 1241 1202 1252 1212 1264 1223 1275 1233 1286 1243 1298 1253 1309 1263 1320 1274 1332 1284 1343 1294 1354 1304 1366 1314 1377 1325 1388 1335 1400 1345 1411 1355 1421 1366 1431 1378 1442 1389 1452 1400 1463 1412 1473 1423 1484 1434 1494 1446 1504 1457 1515 1468 1525 1480 1536 1491 1546 1502 1556 1514 1567 1525 1577 1536 1588 1548 1598 1559 1609 1571 1619 1582 1629 1593 1641 1606 1650 1616 1660 1627 1671 1639 1681 1650 1692 1661 1702 1673 1713 1684 1723 1695 1734 1707 1744 1718 1754 1729 1765 1741 1775 1751 1785 1762 1796 1772 1806 1783 Household Size

3 4 1143 1095 1154 1105 1164 1115 1174 1125 1184 1135 1194 1146 1205 1156 1215 1166 1225 1176 1235 1186 1245 1197 1256 1207 1266 1217 1276 1227 1286 1237 1296 1248 1306 1258 1317 1269 1329 1280 1340 1292 1351 1303 1363 1314 1374 1326 1386 1337 1397 1348 1408 1360 1420 1371 1431 1382 1442 1394 1454 1405 1465 1416 1477 1428 1488 1439 1499 1450 1511 1462 1522 1473 1533 1484 1545 1496 1557 1509 1567 1519 1579 1530 1590 1541 1601 1553 1613 1564 1624 1575 1635 1587 1647 1598 1658 1610 1669 1621 1681 1632 1692 1644 1704 1655 1715 1666 1726 1678 1736 1689 5 6 1045 997 1056 1007 1066 1017 1076 1028 1086 1038 1096 1048 1107 1058 1117 1068 1127 1078 1137 1089 1147 1099 1158 1109 1168 1119 1178 1129 1188 1140 1198 1150 1208 1160 1220 1171 1231 1182 1242 1194 1254 1205 1265 1216 1276 1228 1288 1239 1299 1250 1310 1262 1322 1273 1333 1285 1344 1296 1356 1307 1367 1319 1379 1330 1390 1341 1401 1353 1413 1364 1424 1375 1435 1387 1447 1398 1459 1411 1470 1421 1481 1432 1492 1443 1504 1455 1515 1466 1526 1477 1538 1489 1549 1500 1560 1512 1571 1523 1583 1534 1594 1546 1606 1557 1617 1568 1628 1580 1644 1591 9 CSR 10-31

7 8 948 900 959 910 969 920 979 931 989 941 999 951 1010 961 1020 971 1030 981 1040 992 1050 1002 1061 1012 1071 1022 1081 1032 1091 1043 1101 1053 1111 1063 1123 1074 1134 1085 1145 1097 1157 1108 1168 1119 1179 1131 1191 1142 1202 1153 1213 1165 1225 1176 1236 1188 1247 1199 1259 1210 1270 1222 1282 1233 1293 1244 1304 1256 1316 1267 1327 1279 1338 1290 1350 1301 1362 1314 1372 1324 1384 1335 1395 1347 1406 1358 1418 1369 1429 1381 1440 1392 1452 1403 1463 1415 1474 1426 1486 1437 1497 1449 1509 1460 1520 1471 1531 1483 1543 1494 9 10 850 801 861 812 872 823 882 834 892 844 902 855 912 865 923 875 933 885 943 895 953 906 964 916 974 926 984 936 994 946 1004 957 1014 967 1025 978 1037 989 1048 1001 1059 1012 1071 1023 1082 1035 1094 1046 1105 1057 1116 1069 1128 1080 1139 1091 1150 1103 1162 1114 1173 1125 1184 1137 1196 1148 1207 1159 1218 1171 1230 1182 1241 1193 1252 1205 1265 1217 1275 1228 1286 1239 1298 1250 1309 1262 1321 1273 1332 1284 1343 1296 1355 1307 1366 1318 1377 1330 1389 1341 1400 1352 1412 1364 1423 1375 1434 1386 1446 1398 Adjusted Gross Monthly Income To and From Including 13063 13137 13138 13212 13213 13287 13288 13362 13363 13437 13438 13512 13513 13587 13588 13662 13663 13737 13738 13812 13813 13887 13888 13962 13963 14037 14038 14112 14113 14187 14188 14262 14263 14337 14338 14412 14413 14487 14488 14562 14563 14637 14638 14712 14713 14787 14788 14862 14863 14937 14938 15012 15013 15087 15088 15162 15163 15237 15238 15312 15313 15387 15388 15462 15463 15537 15538 15612 15613 15687 15688 15762 15763 15837 15838 15912 15913 15987 15988 16062 16063 16137 16138 16212 16213 16287 16288 16362 16363 16437 16438 16512 16513 16587 16588 16662 16663 16737 16738 16812 16813 16887 16888 16962 16963 17037 17038 17112 17113 17187 17188 17262 17263 17337 17338 17412 17413 17487 17488 17562 17563 17637 1 2 1817 1793 1827 1803 1838 1814 1848 1824 1859 1835 1869 1845 1879 1855 1890 1866 1900 1876 1910 1887 1921 1897 1931 1908 1942 1918 1952 1928 1963 1939 1973 1949 1984 1960 1994 1970 2004 1980 2015 1991 2025 2001 2035 2012 2046 2022 2056 2032 2067 2043 2077 2053 2088 2064 2097 2073 2109 2085 2119 2095 2129 2105 2140 2116 2150 2126 2160 2137 2171 2147 2181 2157 2192 2168 2202 2178 2213 2189 2223 2199 2234 2210 2244 2220 2254 2230 2265 2241 2275 2251 2285 2262 2296 2272 2306 2282 2317 2293 2327 2303 2338 2314 2348 2324 2359 2335 2369 2345 2379 2355 2390 2366 2400 2376 2410 2387 2421 2397 2431 2407 2442 2418 Household Size

3 4 1747 1700 1757 1711 1768 1722 1778 1732 1789 1743 1799 1753 1809 1763 1820 1774 1830 1784 1840 1794 1851 1805 1861 1815 1872 1826 1882 1836 1893 1847 1903 1857 1914 1867 1924 1878 1934 1888 1945 1899 1955 1909 1965 1919 1976 1930 1986 1940 1997 1951 2007 1961 2018 1972 2027 1981 2039 1992 2049 2003 2059 2013 2070 2024 2080 2034 2090 2044 2101 2055 2111 2065 2122 2076 2132 2086 2143 2097 2153 2107 2164 2117 2174 2128 2184 2138 2195 2149 2205 2159 2215 2169 2226 2180 2236 2190 2247 2201 2257 2211 2268 2221 2278 2232 2289 2242 2299 2253 2309 2263 2320 2274 2330 2284 2340 2294 2351 2305 2361 2315 2372 2326 5 6 1651 1602 1662 1614 1674 1625 1685 1636 1696 1648 1706 1659 1717 1670 1727 1681 1738 1692 1748 1702 1758 1712 1769 1723 1779 1733 1789 1743 1800 1754 1810 1764 1821 1775 1831 1785 1842 1796 1852 1806 1863 1816 1873 1827 1883 1837 1894 1848 1904 1858 1914 1868 1925 1879 1934 1888 1946 1900 1956 1910 1967 1921 1977 1931 1988 1941 1998 1952 2008 1962 2019 1973 2029 1983 2039 1993 2050 2004 2060 2014 2071 2025 2081 2035 2092 2046 2102 2056 2113 2066 2123 2077 2133 2087 2144 2098 2154 2108 2164 2118 2175 2129 2185 2139 2196 2150 2206 2160 2217 2170 2227 2181 2238 2191 2248 2202 2258 2212 2269 2223 2279 2233 7 8 1554 1506 1565 1517 1577 1528 1588 1540 1599 1551 1611 1562 1622 1574 1633 1585 1645 1596 1656 1608 1666 1619 1677 1630 1687 1642 1698 1652 1708 1662 1719 1673 1729 1683 1739 1693 1750 1704 1760 1714 1771 1725 1781 1735 1791 1746 1802 1756 1812 1766 1823 1777 1833 1787 1843 1797 1854 1808 1864 1818 1875 1829 1885 1839 1896 1850 1906 1860 1916 1871 1927 1881 1937 1891 1948 1902 1958 1912 1968 1923 1979 1933 1989 1943 2000 1954 2010 1964 2021 1975 2031 1985 2041 1996 2052 2006 2062 2016 2073 2027 2083 2037 2093 2048 2104 2058 2114 2068 2125 2079 2135 2089 2146 2100 2156 2110 2166 2121 2177 2131 2187 2141 9 10 1457 1409 1468 1420 1480 1432 1491 1443 1502 1455 1514 1466 1525 1477 1536 1489 1548 1500 1559 1511 1570 1523 1582 1534 1593 1545 1604 1557 1616 1568 1627 1579 1637 1591 1647 1602 1658 1613 1668 1623 1679 1634 1689 1644 1699 1654 1710 1665 1720 1675 1731 1686 1741 1696 1751 1706 1762 1717 1772 1727 1783 1738 1793 1748 1804 1759 1814 1769 1824 1779 1835 1790 1845 1800 1856 1811 1866 1821 1877 1832 1887 1842 1897 1852 1908 1863 1918 1873 1929 1884 1939 1894 1949 1904 1960 1915 1970 1925 1981 1936 1991 1946 2002 1956 2012 1967 2022 1977 2033 1988 2043 1998 2054 2009 2064 2019 2074 2029 2085 2040 2095 2050 Adjusted Gross Monthly Income To and From Including 17638 17712 17713 17787 17788 17862 17863 17937 17938 18012 18013 18087 18088 18162 18163 18237 18238 18312 18313 18387 18388 18462 18463 18537 18538 18612 18613 18687 18688 18762 18763 18837 18838 18912 18913 18987 18988 19062 19063 19137 19138 19212 19213 19287 19288 19362 19363 19437 19438 19512 19513 19587 19588 19662 19663 19737 19738 19812 19813 19887 19888 19962 19963 20037 20038 20112 20113 20187 20188 20262 20263 20337 20338 20412 20413 20487 20488 20562 20563 20637 20638 20712 20713 20787 20788 20862 20863 20937 1 2 2452 2428 2463 2439 2473 2449 2484 2460 2494 2470 2504 2480 2515 2491 2525 2501 2535 2511 2546 2522 2556 2532 2567 2543 2577 2553 2588 2564 2598 2574 2608 2585 2619 2595 2629 2605 2640 2616 2650 2626 2660 2636 2671 2647 2681 2657 2692 2668 2702 2678 2713 2689 2723 2699 2733 2710 2744 2720 2754 2730 2765 2741 2775 2751 2785 2761 2796 2772 2806 2782 2817 2793 2827 2803 2838 2814 2848 2824 2858 2835 2869 2845 2879 2855 2890 2866 2900 2876 Household Size

3 4 2382 2336 2393 2346 2403 2357 2414 2367 2424 2378 2434 2388 2445 2399 2455 2409 2465 2419 2476 2430 2486 2440 2497 2451 2507 2461 2518 2471 2528 2482 2539 2492 2549 2503 2559 2513 2570 2524 2580 2534 2590 2544 2601 2555 2611 2565 2622 2576 2632 2586 2643 2596 2653 2607 2663 2617 2674 2628 2684 2638 2695 2649 2705 2659 2715 2669 2726 2680 2736 2690 2747 2701 2757 2711 2768 2721 2778 2732 2788 2742 2799 2753 2809 2763 2820 2774 2830 2784 5 6 2289 2243 2300 2254 2310 2264 2321 2275 2331 2285 2342 2295 2352 2306 2363 2316 2373 2327 2383 2337 2394 2348 2404 2358 2414 2368 2425 2379 2435 2389 2446 2400 2456 2410 2467 2420 2477 2431 2488 2441 2498 2452 2508 2462 2519 2473 2529 2483 2539 2493 2550 2504 2560 2514 2571 2525 2581 2535 2592 2545 2602 2556 2612 2566 2623 2577 2633 2587 2644 2598 2654 2608 2664 2618 2675 2629 2685 2639 2696 2650 2706 2660 2717 2670 2727 2681 2737 2691 9 CSR 10-31

7 8 2198 2152 2208 2162 2218 2173 2229 2183 2239 2193 2250 2204 2260 2214 2271 2225 2281 2235 2291 2245 2302 2256 2312 2266 2323 2277 2333 2287 2343 2298 2354 2308 2364 2318 2375 2329 2385 2339 2396 2350 2406 2360 2416 2370 2427 2381 2437 2391 2447 2402 2458 2412 2468 2423 2479 2433 2489 2443 2500 2454 2510 2464 2521 2475 2531 2485 2541 2495 2552 2506 2562 2516 2572 2527 2583 2537 2593 2548 2604 2558 2614 2568 2625 2579 2635 2589 2646 2600 9 10 2106 2061 2116 2071 2127 2081 2137 2092 2147 2102 2158 2113 2168 2123 2179 2134 2189 2144 2199 2154 2210 2165 2220 2175 2231 2186 2241 2196 2252 2206 2262 2217 2272 2227 2283 2238 2293 2248 2304 2259 2314 2269 2324 2279 2335 2290 2345 2300 2356 2311 2366 2321 2377 2331 2387 2342 2397 2352 2408 2363 2418 2373 2429 2384 2439 2394 2449 2404 2460 2415 2470 2425 2481 2435 2491 2446 2502 2456 2512 2467 2522 2477 2533 2488 2543 2498 2554 2509