Please complete this form and upload any requested documentation. By submitting this form, you are sending this form securely to The Aliveness Project. We request this information every six months as requested by our funding sources. If more information is needed, we will contact you. If you have any questions, please call us at 612.822.7946 or email email@example.com.
NOTE: You will not be denied any services even if your income exceeds guidelines. Our services are available to anyone living with HIV/AIDS. We must collect this information as a requirement of government grants we received for specific programs.
City, State, Zip Code
Are we able to send mail to you?
Are we able to call you?
My annual income is:
Do you meet Federal Poverty Guidelines? (see right)
Yes, I meet the amount
No, I exceed the amount
I have no personal income
Federal Poverty Level Guidelines:
Household Size: 1 & Income Level: $48,240
Household Size: 2 & Income Level: $64,690
Household Size: 3 & Income Level: $81,680
Household Size: 4 & Income Level: $98,400
Household Size: 5 & Income Level: $115,120
Household Size: 6 & Income Level: $131,840
If you selected no personal income, please select:
One or more of my family members are working or own a business.
One or more of my family members receives child support, SSI, SSDI, pension, etc.
One or more of my family members gets money from a friend, relative, or organization.
A relative, friend, or organization pays all my bills & expenses.
I pay bills from money in savings, checking, trust fund account, or proceeds of sales of personal items.
If your income is below Federal Poverty Level guidelines as shown above, please upload proof of income such as copy of pay stubs, benefit letters, or tax return. If your income exceeds guidelines or you have no income, you are not required to provide proof.
Medical Information Update
Required for Federal Funding
Date of my last HIV/AIDS medical appointment
Only sees doctor every 12 months
Do you have health insurance?
What type of health insurance do you have?
Medicaid (MA in MN, CHIP, or other public)
Private - Employer
Private - Individual
VA, Tricare, Other Military Health Care
Indian Health Services
If you have multiple sources of health insurance, please list secondary:
Please upload proof of health insurance which can be a copy of a health insurance card or documentation of active health insurance.
What is your housing status currently?
Stable/Permanent (ex. rental, home-owner)
Unstable (ex. homeless)
Temporary (ex. with friends/relatives, treatment facility, transitional housing)
Please upload proof of MN residency which can be a MN state ID, MN driver's license, copy of lease, or copy of utility bills.
By providing my electronic signature, I understand that this serves as a signature of certification that the above information is true and correct. I understand that this information will be submitted to The Aliveness Project as updated information needed for funding purposes and will remain secure, private information. If the above information changes, I will notify The Aliveness Project and provide updated documentation as needed.