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  • DOES YOUR FAMILY FIT WITHIN THE ABOVE INCOME GUIDELINES?*
  • ARE YOU, OR SOMEONE IN YOUR FAMILY, A CARD CARRYING MEMBER OF A FEDERALLY RECOGNIZED TRIBE?*
  • DO YOU CURRENTLY HAVE ANY INSURANCE (OR HAVE ANY OFFERED TO YOU, EVEN IF YOU'RE NOT ENROLLED) SUCH AS: EMPLOYER INSURANCE OR HRA THROUGH YOU OR YOUR SPOUSE'S JOB, VA OR TRICARE, MEDICARE/MEDICAID?*

  • Should be Empty: