Proof of Income & Eligibility Form
Aliveness members are asked to complete this form at least every six months. Thank you for helping us keep our services FREE and available to all folks living with HIV!
Aliveness Member Number
Four digits - also called an Access Pass
Street Address Line 2
District of Columbia
Are you comfortable receiving mail from Aliveness?
May Aliveness call you on the phone?
My annual income is:
If you have no personal income, how do you pay your expenses? Check all that apply.
My family member(s) are working or own a business.
My family member(s) receive child support, SSI, SSDI, pension, etc.
My family member(s) get money from a friend, relative, or organization.
A relative, friend, or organization pays all my expenses.
I pay my expenses from money in savings, checking, trust fund account, or the sale of personal items.
Number of People in My Household:
Please include children, family, live-in partners if you share finances. If you live alone or support only yourself financially, you have a household of 1.
Please upload PROOF OF INCOME - examples: pay stubs, benefit letter, tax return, etc.
You are not required to provide proof if you have no income. You are also not required to provide proof if your income exceeds 400% of the Federal Poverty Guidelines (income over $51,040 for one person or over $68,960 for a two-person household). ALL members with income between 0 and $51,040 must upload a document to show your income.
Date of my last HIV/AIDS medical appointment
How often do you see your HIV/AIDS doctor?
Every 3-6 months
Once a year (every 12 months)
I am not currently receiving medical care and treatment for my HIV
What type of health insurance do you have? You can check more than one option.
Medicaid (MA, MinnesotaCare):
VA, Tricare, or other military health care:
Private - employer:
Private - individual:
Indian Health Services:
I have health insurance, but do not know what type:
I do not have health insurance right now:
Please upload PROOF OF HEALTH INSURANCE - examples: a picture of your health insurance card, document showing active health insurance, etc.
What is your housing status?
Stable/Permanent (rental, homeowner)
Temporary (with friends/relatives, treatment facility, transitional housing)
Unstable (homeless, staying in or out of shelter)
Please upload PROOF OF MINNESOTA RESIDENCY - examples: MN state ID, MN driver's license, picture of lease or utility bill
Signature (use your finger or mouse to sign)
Should be Empty: