[34 Pa.B. 5044]
[Continued from previous Web Page]
NOTIFICATION AND RIGHT TO APPEAL § 3041.161. General notification requirements.
(a) The eligibility agency shall notify the parent or caretaker in writing no later than 10 calendar days prior to taking an action that affects the family's eligibility status for subsidized child care or a change in the amount of the family's subsidized child care benefit.
(b) Following the preparation of a written notice, the eligibility agency shall:
(1) Mail or hand-deliver within 1 working day of preparation, the original and one copy of the notice to the parent or caretaker.
(2) Notify the family's child care provider as soon as the family is determined eligible or ineligible for subsidized child care.
(3) Retain a copy of the notice in the family file as specified in § 3041.84 (relating to family file).
§ 3041.162. Notice of right to appeal.
The following information shall be included in the notice of the right to appeal:
(1) The statement regarding the parent's or caretaker's right to appeal.
(2) The time frame associated with filing a timely appeal as specified in §§ 3041.174(d) and 3041.176(b) (relating to parent or caretaker rights and responsibilities; and hearing procedures).
(3) The time frame associated with subsidy continuation as specified in § 3041.173 (relating to subsidy continuation during the appeal process).
(4) The consequence of filing an appeal untimely.
(5) The responsibility to repay if subsidy continues and the parent or caretaker does not win the appeal.
§ 3041.163. Notice of eligibility.
(a) The notice of eligibility shall be on a form provided by the Department.
(b) If the eligibility agency determines a family eligible for subsidy upon initial application, at the time of redetermination or at a review of a reported change, the written notification shall include the following:
(1) The amount of the co-payment.
(2) The parent's or caretaker's responsibility to pay the co-payment as specified in § 3041.101(e) (relating to general co-payment requirements).
(3) The parent's or caretaker's responsibility to pay an equivalent advance co-payment.
(4) The parent's or caretaker's responsibility to report changes as specified in § 3041.127 (relating to parent and caretaker report of change).
(5) The name, address and telephone number of the local legal services office where the parent or caretaker may obtain free legal representation.
(6) The right of the parent or caretaker to appeal the decision and how to appeal as specified in §§ 3041.162 and 3041.171 (relating to notice of right to appeal; and appealable actions).
§ 3041.164. Notice of ineligibility.
(a) The notice of ineligibility must be on a form provided by the Department.
(b) If the eligibility agency determines a family ineligible for subsidy upon initial application, at the time of redetermination or at a review of a reported change, the written notification shall include the following:
(1) The decision.
(2) The reason for the decision.
(3) A citation, and brief explanation in simple, nontechnical language, of the applicable section of this chapter or other applicable law that was the basis for the decision.
(4) The name, address and telephone number of the local legal services office where the parent or caretaker may obtain free legal representation.
(5) The right of the parent or caretaker to appeal the decision and how to appeal as specified in §§ 3041.162 and 3041.171 (relating to notice of right to appeal; and appealable actions).
§ 3041.165. Notice of adverse action.
(a) The eligibility agency shall send a notice to a parent or caretaker currently receiving subsidy when the eligibility agency proposes to terminate, suspend or disrupt subsidy payment or to increase the family co-payment.
(b) The eligibility agency shall prepare a notice of adverse action on a form provided by the Department.
(c) The notice of adverse action must include:
(1) The decision or proposed action.
(2) The date the action will occur.
(3) The reason for the decision or proposed action and information about how to become eligible.
(4) A citation, and brief explanation in simple, nontechnical language, of the applicable section of this chapter or other applicable law that is the basis for the decision or proposed action.
(5) The name, address and telephone number of the local legal services office where the parent or caretaker may obtain free legal representation.
(6) The right of the parent or caretaker to appeal the decision and how to appeal as specified in §§ 3041.162 and 3041.171 (relating to notice of right to appeal; and appealable actions).
§ 3041.166. Notice confirming voluntary withdrawal.
The eligibility agency shall, by written notice to the parent or caretaker, confirm the parent's or caretaker's voluntary withdrawal of a child from subsidized child care.
§ 3040.167. Notice of overpayment.
(a) The eligibility agency shall notify the parent or caretaker in writing of an overpayment.
(b) The notification may also include a notice of adverse action if the overpayment affects the amount of the co-payment or results in suspension or termination.
(c) The notice of overpayment must include the following:
(1) The reason for the overpayment as specified in § 3041.181 (relating to overpayment).
(2) The period of the overpayment.
(3) The amount of the overpayment.
(4) An explanation of how the overpayment was calculated.
(5) The repayment methods as specified in § 3040.186 (relating to collection).
(6) The right of the parent or caretaker to appeal the decision on the overpayment amount and how to appeal as specified in §§ 3041.162 and 3041.171 (relating to notice of right to appeal; and appealable actions).
APPEAL AND HEARING PROCEDURES § 3041.171. Appealable actions.
A parent or caretaker has the right to appeal a Departmental or eligibility agency action or failure to act, including the following:
(1) Denial of subsidy.
(2) Termination of subsidy.
(3) Computation of the co-payment.
(4) Denial of a request for wavier of a requirement of this chapter based on domestic violence as specified in § 3041.91 (relating to general requirements).
(5) Failure of the eligibility agency to act upon a request for subsidy within the time limits specified in this chapter.
(6) Subsidy suspension, as specified in § 3040.21 (relating to subsidy suspension).
(7) Subsidy disruption, as specified in § 3040.22 (relating to subsidy disruption)
§ 3041.172. Discontinuation of subsidy.
Subsidy is not continued pending a hearing decision if the parent or caretaker appeals the disruption of subsidy when the eligibility agency lacks funding to continue subsidy to a child as specified in § 3041.22 (relating to subsidy disruption).
§ 3041.173. Subsidy continuation during the appeal process.
(a) Subsidy continues at the prior level until the appeal is heard and a final decision is made by the Department, if the parent or caretaker meets the following conditions:
(1) Appeals no later than 10 calendar days after the date the written notice is postmarked or hand-delivered to the parent or caretaker by the eligibility agency.
(2) Appeals for a reason other than disruption of subsidy or a lack of funding.
(b) If subsidy continues as specified in subsection (a), the parent or caretaker shall continue to make timely payment of the co-payment that was in effect prior to issuance of the notice of adverse action until a final decision is made by the Department, as specified in § 3041.101 (relating to general co-payment requirements).
(c) If subsidy continues during the appeal process and the hearing officer finds in favor of the eligibility agency or the Department, the parent or caretaker shall reimburse the Department for the amount of the subsidy or increase in subsidy paid for child care from the proposed effective date of the adverse action until the date subsidy is terminated or decreased, based on the final administrative action order.
§ 3041.174. Parent or caretaker rights and responsibilities.
(a) A parent or caretaker appealing an adverse action shall submit a written request to the eligibility agency in accordance with Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings). The parent or caretaker shall specify the reason for the appeal, the current address and a telephone number, if possible, where the parent or caretaker can be reached during the day.
(b) A parent or caretaker may orally appeal. The eligibility agency shall document the date of the oral appeal in the case file. The parent or caretaker shall confirm the oral appeal in writing to the eligibility agency no later than 7 calendar days following the date the parent or caretaker orally requested an appeal.
(c) A parent or caretaker may authorize an adult to represent him at the hearing.
(d) If the parent or caretaker wants subsidy to continue pending a hearing decision, subject to § 3041.173 (relating to subsidy continuation during the appeal process), the parent or caretaker shall submit a written appeal no later than 10 calendar days following the date the written notice is postmarked or hand-delivered to the parent or caretaker by the eligibility agency.
(e) If the parent or caretaker requests that subsidy continue pending a hearing decision, the parent or caretaker shall make timely payment of the co-payment that was in effect prior to issuance of the notice of adverse action until a final decision is made by the Department, as specified in § 3041.101 (relating to general co-payment requirements).
§ 3041.175. Eligibility agency responsibilities.
(a) If the parent or caretaker is unable to prepare a written appeal, the eligibility agency shall assist the parent or caretaker in preparing a written appeal. The parent or caretaker shall sign the appeal request.
(b) Upon receipt of the appeal, the eligibility agency shall date-stamp the appeal, the envelope and the attachments with the date of receipt and retain copies of all original appeal information.
(c) The eligibility agency shall keep a copy and forward the original appeal along with the postmarked envelope to the Department's Bureau of Hearings and Appeals no later than 3 working days following the date the appeal is received by the eligibility agency.
(d) The eligibility agency may not take the proposed adverse action until 10 calendar days following the date the written notice is postmarked or hand-delivered to the parent or caretaker and then only if the parent or caretaker has not filed an appeal. Subsidy may be continued at the prior level only if the parent or caretaker meets the requirements in § 3041.173 (relating to subsidy continuation during the appeal process).
(e) The eligibility agency may take the proposed adverse action before 10 calendar days following the date a provider closes for financial difficulties or loss of certification or registration or if funding is not available to continue subsidized care to the child.
§ 3041.176. Hearing procedures.
(a) Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings) applies to hearings that are held under this chapter, except as specifically superseded by this chapter.
(b) An appeal postmarked or received after 30 calendar days from the date the written notice is postmarked or hand-delivered to the parent or caretaker will be dismissed as untimely without a hearing, unless one of the provisions allowing for appeals after 30 calendar days applies as specified in § 275.3(b)(2) and (3) (relating to time limitations on right to appeal).
(c) The hearing may be conducted by a telephone conference call with the parties to the appeal, including the parent or caretaker, the authorized representative of the parent or caretaker, the eligibility agency, the Department and the hearing officer.
(d) The parent or caretaker has the right to request a face-to-face hearing instead of a telephone hearing. Face-to-face hearings will be held in locations specified by the Department.
(e) If a parent or caretaker does not withdraw an appeal the eligibility agency, or the Department if appropriate, will take part in the scheduled hearing to justify the action to which the parent or caretaker objects.
(f) If the eligibility agency or the Department fails to appear at the hearing and the parent or caretaker appear, the parent's or caretaker's appeal will be sustained.
(g) If the parent or caretaker fails to appear for the hearing, regardless of whether the eligibility agency or the Department appears, the appeal is considered abandoned and the decision of the eligibility agency or the Department will be sustained.
(h) The Department will notify the eligibility agency and the parent or caretaker, in writing, when disposition of the appeal is made.
(i) The eligibility agency shall implement the final administrative action within the time limit ordered by the Department or on the first day child care is needed in the week following receipt of the final administrative action order.
OVERPAYMENT AND DISQUALIFICATION § 3041.181. Overpayment.
The parent or caretaker may not be required to repay an overpayment except for an overpayment resulting from one of the following:
(1) Fraud.
(2) Failure to comply with this chapter.
(3) Subsidy continuation pending an appeal when the parent or caretaker did not win the appeal.
§ 3041.182. Eligibility agency responsibilities.
(a) The eligibility agency shall inform a parent or caretaker who files an appeal and requests subsidy continuation pending appeal, that if the hearing decision is in favor of the eligibility agency or the Department, the parent or caretaker shall reimburse the amount of the overpayment unless the hearing officer determines a hardship.
(b) The eligibility agency shall pursue possible overpayments in active and closed cases, including those that were voluntarily closed.
(c) The following are the responsibilities of the eligibility agency when exploring possible overpayments:
(1) Determination of whether the overpayment is the result of one of the conditions specified in § 3041.181 (relating to overpayment).
(2) Written assurance that the methods of exploring overpayments are appropriate to the particular situation and to the different eligibility factors.
(3) Assurance that the methods of exploring overpayments do not infringe on the civil liberties of individuals or interfere with the due process of law.
(4) Investigation of a credible complaint that a parent or caretaker is erroneously receiving subsidized child care.
(5) Identification and documentation of the causes of the overpayment.
(6) Computation of the amount of the overpayment.
(7) Referral of suspected fraud cases to the Office of Inspector General.
(8) Submission of an overpayment notice to the parent or caretaker as specified in § 3041.167 (relating to notice of overpayment).
§ 3041.183. Delaying recoupment.
Recoupment shall be delayed until after a hearing decision, if the family appeals the overpayment decision no later than 10 calendar days after the date the written notice is postmarked or hand-delivered to the parent or caretaker by the eligibility agency.
§ 3041.184. Notifying the Department.
The eligibility agency shall notify the Department when recoupment stops before the overpayment is fully recouped.
§ 3041.185. Repayment.
The parent or caretaker shall repay the eligibility agency or Department the full amount of the overpayment.
§ 3041.186. Collection.
(a) The eligibility agency shall collect the total amount of the overpayment from a family whose child continues to receive subsidized child care when the eligibility agency identifies an overpayment.
(b) If the Department, eligibility agency or other entity identifies an overpayment subject to repayment as specified in § 3041.181 (relating to overpayment) related to a family whose child continues to receive subsidized child care, the eligibility agency shall:
(1) Notify the parent or caretaker by a letter that a repayment is required, the amount of the repayment and the following repayment options:
(i) A one-time payment of the full amount owed.
(ii) A one-time partial payment and an increase in the co-payment to be paid until repayment is complete.
(iii) An increase in the co-payment until the repayment is complete.
(2) Automatically implement an increase to the co-payment until the repayment is complete when the parent or caretaker does not select an option as specified in paragraph (1) no later than 10 calendar days following the date of the letter.
(3) Notify the parent or caretaker by a second letter of failure to choose a repayment option as specified in paragraph (1), the amount of the increased co-payment and the number of weeks the increased co-payment will continue.
§ 3041.187. Co-payment increase.
(a) A co-payment increase for the purpose of collecting an overpayment may not exceed an amount greater than 5% of the family's gross monthly income. If the parent or caretaker indicates to the eligibility agency that an increase to 5% would cause hardship to the family, the family and the eligibility agency may agree to a lesser amount.
(b) A parent or caretaker may choose to increase the co-payment beyond the amount specified in subsection (a) to repay an overpayment in a shorter period of time.
(c) The eligibility agency shall issue a written notice of adverse action as specified in §§ 3041.161 and 3041.165 (relating to general notification requirements; and notice of adverse action) before implementation of an increase in the co-payment.
§ 3041.188. Collection for a family whose child is no longer in care.
(a) The eligibility agency shall collect the total amount of the overpayment from a family whose child is no longer receiving subsidized child care if the eligibility agency identifies an overpayment.
(b) If the Department, eligibility agency or other entity identifies an overpayment for a family whose child is no longer receiving subsidized child care, the eligibility agency shall:
(1) Notify the Department of the subsidy termination date, the amount of the overpayment recouped and the amount outstanding. The Department will notify the parent or caretaker by letter of the overpayment, the amount of the outstanding overpayment and that full repayment is required. The letter must state that the parent or caretaker has 10 calendar days to respond to the Department indicating agreement or disagreement and indicating the choice of a repayment method.
(2) Send a second letter that repeats the information contained in the letter specified in paragraph (1) when the Department notifies the eligibility agency that the parent or caretaker failed to respond. The second letter must also request a response from the parent or caretaker no later than 10 calendar days following the date of the letter.
(c) The Department may institute civil legal proceedings when the parent or caretaker fails to respond to the second letter.
§ 3041.189. Disqualification.
(a) The parent or caretaker is disqualified from participating in the subsidized child care program if one of the following applies:
(1) A Federal or State court finds the parent or caretaker guilty of fraud in applying for or receiving subsidized child care.
(2) A hearing officer determines that the parent or caretaker committed fraud, pursuant to the procedures and standards in Chapter 275 (relating to administrative disqualification hearings).
(3) The parent or caretaker signs a disqualification consent agreement as part of a court's deferred adjudication process.
(b) Upon disqualification under subsection (a), a parent or caretaker and eligible children in the parent's or caretaker's family shall be prohibited from participation in the subsidized child care program:
(1) For 6 months from the date of the first conviction, hearing decision or determination.
(2) For 12 months from the second conviction, hearing decision or determination.
(3) Permanently from the date of the third conviction, hearing decision or determination.
(c) A parent or caretaker may not be granted a hearing on a court conviction or administrative disqualification hearing decision that led to the disqualification.
APPENDIX A
INCOME TO BE INCLUDED, DEDUCTED AND EXCLUDED IN DETERMINING GROSS MONTHLY INCOME
PART I. INCOME INCLUSIONS. Income from the following sources is included when determining total gross monthly income:
A. Money, wages or salary earned by a parent or caretaker before deductions for taxes, Social Security, savings bonds, pensions, union dues, health insurance and similar purposes, for work performed as an employee. This includes commissions, tips, piece-rate payments and cash bonuses. Income earned by an unemancipated minor is not included.
B. Armed forces pay which includes base pay plus cash, but does not include housing subsistence, allowances or the value of rent-free quarters.
C. Voluntary and court-ordered support received for any person in the family.
D. Net income from nonresident and real property, defined as gross receipts minus the expenses for continuing the income, such as depreciation charges, business taxes (not personal income taxes), interest on mortgages, repairs and similar expenses.
E. Social Security benefits, Supplemental Security Income, survivors' benefits and permanent disability insurance payments made by the Social Security Administration before deductions of health insurance premiums.
F. Railroad retirement, disability or survivors' benefit payments made by the United States Government under the Railroad Retirement Act, before deductions of health insurance premiums.
G. State blind pension payments made by the Department.
H. Public assistance or welfare benefits or retirement benefits.
I. Private pensions and annuities, including retirement benefits paid to a retired person or his survivors by a former employer or a union, either directly or through an insurance company.
J. Government employee pensions paid by Federal, State, county or other governmental agencies to former employees, including members of the armed forces, or their survivors.
K. Unemployment compensation received from government unemployment insurance agencies or private companies during periods of unemployment and strike benefits received from union funds.
L. Workers' compensation received from private or public insurance companies.
M. Veterans' payments, defined as money paid periodically by the Veterans Administration (VA) to disabled members of the armed forces or to the survivors or dependents of deceased or disabled veterans, subsistence allowances paid to the survivors of deceased veterans and subsistence allowances paid to veterans for education and on-the-job training, as well as so-called ''refunds'' paid to ex-service persons as GI insurance premiums. For the disabled veteran in the Vocational Rehabilitation Program, the subsistence allowance and the veteran's disability allowance are counted as income.
N. Capital gains, profit from S-corporations and dividends, including dividends from stocks, bonds, mutual funds or from membership in an association.
O. Interest on savings and bonds.
P. Income from estates and trust funds.
Q. Net income from royalties.
R. Lump sum cash of more than $100: inheritances, life insurance benefits; personal injury and other damage awards and settlements; retroactive benefits such as Retirement, Survivor's or Disability Insurance and delayed Unemployment, divorce settlements, gifts or Worker's Compensation.
S. Lump sum cash lottery winnings or cash prizes of more than $100.
T. Profit from self-employment; total gross receipts minus costs of doing business. The costs of doing business include:
(1) Costs of maintaining a place of business such as rent, utilities, insurance on the business and its property and property taxes. Note: If a business is operated in a home, the costs of maintaining a place of business are only those costs identified for the part of the home used exclusively for the business.
(2) Interest on the purchase of income-producing equipment and property.
(3) Employee labor costs, such as wage, salaries, taxes, benefits, Unemployment Compensation or Worker's Compensation.
(4) Cost of goods sold, supplies and materials.
(5) Advertising costs.
(6) Accounting and legal fees.
(7) Professional licensing fees and union dues, if necessary to practice a profession or trade.
(8) Transportation costs necessary to produce income.
(9) Depreciation.
(10) Other deductions allowed by the Internal Revenue Service (IRS).
U. Net income from room rent or room and board: Gross income received minus $10 per month for each room rented. Divide the remainder by 2. That number is the income inclusion.
CONVERSION TABLE Convert weekly, biweekly, semi-monthly and other pay periods to gross monthly amounts using the following Conversion Table:
Frequency of income Conversion method Daily Multiply the daily income by the number of workdays in a week, then multiply by 4.3. Weekly Multiply by 4.3. Biweekly (every 2 weeks) Divide by 2, then multiply by 4.3. Semimonthly (twice a month) Multiply by 2 for monthly gross income. Monthly Use the figure given. Quarterly Divide by 3. Annually Divide by 12. Lump sum income Divide by 12.
PART II. INCOME DEDUCTIONS. The following are deducted when determining adjusted monthly income:
A. Voluntary or court-ordered support paid by the parent or caretaker or a family member to a present or former spouse not residing in the same household.
B. Voluntary or court-ordered child support paid by the parent or caretaker or family member to a person not residing in the same household.
C. A medical expense not reimbursed through medical insurance that exceeds 10% of the family gross monthly income. The medical expense must have been incurred within the 90-day period prior to the date the parent or caretaker notifies the eligibility agency of that expense and there must be an expectation that the expense will continue to be incurred for the 6 months following the outset of the expense. Medical expenses are based on the monthly expenses or monthly payment plan, or both. Medical expenses include bills for doctors, hospital costs, dental services, health care premiums, institutional care, medications, prosthetic devices, durable medical equipment or mental health services.
D. The Basic Living Need Allowance Deduction for stepparents is the pro-rata share of the stepparent's income attributed to support of the stepparent and any child under the care and control of the stepparent for whom subsidy is not sought, but who are considered part of the family as defined in this chapter. To compute this deduction, divide the stepparent's total gross monthly income, less other allowable deductions listed in this section, by the total number of persons in the family. This amount is then multiplied by the number of persons in the family who may be included in the Basic Living Need Allowance Deduction.
PART III. INCOME EXCLUSIONS. Income from the following sources is excluded in determining gross monthly income:
A. Employment earnings of an individual who is an unemancipated minor.
B. Tax refunds, including earned income tax credits.
C. Withdrawals of bank, credit union or brokerage deposits.
D. Money borrowed.
E. Nonrecurring money (in amounts under $100 per person per year) given as a gift, from any source.
F. The value of benefits under the Food Stamp Act of 1977 (7 U.S.C.A. §§ 2011--2036).
G. The value of foods donated from the United States Department of Agriculture.
H. The value of supplemental foods assistance under the Child Nutrition Act of 1966 (42 U.S.C.A. §§ 1771--1791) and the special food service programs for children under that act.
I. Loans and grants, such as scholarships, obtained and used for conditions that preclude their use for living costs.
J. Any grant or loan to an undergraduate student for educational purposes, made or insured under any program administered under the Higher Education Act of 1965 (20 U.S.C.A. §§ 1001--1145-q).
K. Any payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 U.S.C.A. §§ 4601--4655).
L. Any home produce used for household consumption.
M. Any payment made on behalf of an individual for household expenses, such as rent, food and utilities.
N. Payments to Volunteers in Service to America under the Domestic Volunteer Service Act of 1973 (42 U.S.C.A. §§ 4951--5085), which include Americorps income.
O. Earnings received by any youth under the Workforce Investment Act of 1998, as amended; Pub. L. 105--220, Aug. 7, 1998, 112 Stat. 939. (29 U.S.C. 2801 et seq.).
P. Any foster care payments by a foster care placement agency.
Q. Stipends derived from the Foster Grandparent Programs under sections 211 and 212 of the Domestic Violence Service Act of 1973 (42 U.S.C.A. §§ 5011 and 5012).
R. Low Income Home Energy Assistance Program (LIHEAP) benefits and cash in-kind energy assistance provided by private agencies and utility companies.
S. Any adoption assistance payments by a county children and youth agency.
T. Income received from Federal student aid or participation in a Federal work-study program.
U. Payments made by the Veterans Administration to children of Vietnam veterans under The Benefits for Children of Vietnam Veterans Act (38 U.S.C. § 1823c).
APPENDIX B
CO-PAYMENT CHART FAMILY CO-PAYMENT SCALE (BASED ON THE 2004 FEDERAL POVERTY INCOME GUIDELINES)
Weekly Family Size: 1 Family Size: 2 Family Size: 3 Co-pay Annual Income Annual Income Annual Income $5.00 Less than: $7,310 Less than: $10,490 Less than: $11,670 $10.00 $7,310.01 $9,310 $10,490.01 $12,490 $11,670.01 $13,670 $15.00 $9,310.01 $11,310 $12,490.01 $14,490 $13,670.01 $15,670 $20.00 $11,310.01 $13,310 $14,490.01 $16,490 $15,670.01 $17,670 $25.00 $13,310.01 $15,310 $16,490.01 $18,490 $17,670.01 $19,670 $30.00 $15,310.01 $17,310 $18,490.01 $20,490 $19,670.01 $21,670 $35.00 $17,310.01 $19,310 $20,490.01 $22,490 $21,670.01 $23,670 $40.00 $19,310.01 $21,310 $22,490.01 $24,490 $23,670.01 $25,670 $45.00 $21,310.01 $21,879 $24,490.01 $26,490 $25,670.01 $27,670 $50.00 $26,490.01 $28,490 $27,670.01 $29,670 $55.00 $28,490.01 $29,352 $29,670.01 $31,670 $60.00 $31,670.01 $33,670 $65.00 $33,670.01 $35,670 $70.00 $35,670.01 $36,825 200% FPIG $18,620 200% FPIG $24,980 200% FPIG $31,340
Weekly Family Size: 4 Family Size: 5 Family Size: 6 Co-pay Annual Income Annual Income Annual Income $5.00 Less than: $12,850 Less than: $14,030 Less than: $15,210 $10.00 $12,850.01 $14,850 $14,030.01 $16,030 $15,210.01 $17,210 $15.00 $14,850.01 $16,850 $16,030.01 $18,030 $17,210.01 $19,210 $20.00 $16,850.01 $18,850 $18,030.01 $20,030 $19,210.01 $21,210 $25.00 $18,850.01 $20,850 $20,030.01 $22,030 $21,210.01 $23,210 $30.00 $20,850.01 $22,850 $22,030.01 $24,030 $23,210.01 $25,210 $35.00 $22,850.01 $24,850 $24,030.01 $26,030 $25,210.01 $27,210 $40.00 $24,850.01 $26,850 $26,030.01 $28,030 $27,210.01 $29,210 $45.00 $26,850.01 $28,850 $28,030.01 $30,030 $29,210.01 $31,210 $50.00 $28,850.01 $30,850 $30,030.01 $32,030 $31,210.01 $33,210 $55.00 $30,850.01 $32,850 $32,030.01 $34,030 $33,210.01 $35,210 $60.00 $32,850.01 $34,850 $34,030.01 $36,030 $35,210.01 $37,210 $65.00 $34,850.01 $36,850 $36,030.01 $38,030 $37,210.01 $39,210 $70.00 $36,850.01 $38,850 $38,030.01 $40,030 $39,210.01 $41,210 $75.00 $38,850.01 $40,850 $40,030.01 $42,030 $41,210.01 $43,210 $80.00 $40,850.01 $42,850 $42,030.01 $44,030 $43,210.01 $45,210 $85.00 $42,850.01 $44,298 $44,030.01 $46,030 $45,210.01 $47,210 $90.00 $46,030.01 $48,030 $47,210.01 $49,210 $95.00 $48,030.01 $50,030 $49,210.01 $51,210 $100.00 $50,030.01 $51,771 $51,210.01 $53,210 $105.00 $53,210.01 $55,210 $110.00 $55,210.01 $57,210 $115.00 $57,210.01 $59,210 $120.00 $59,210.01 $59,244 200% FPIG $37,700 200% FPIG $44,060 200% FPIG $50,420
Weekly Family Size: 7 Family Size: 8 Family Size: 9 Co-pay Annual Income Annual Income Annual Income $5.00 Less than: $16,390 Less than: $17,570 Less than: $18,750 $10.00 $16,390.01 $18,390 $17,570.01 $19,570 $18,750.01 $20,750 $15.00 $18,390.01 $20,390 $19,570.01 $21,570 $20,750.01 $22,750 $20.00 $20,390.01 $22,390 $21,570.01 $23,570 $22,750.01 $24,750 $25.00 $22,390.01 $24,390 $23,570.01 $25,570 $24,750.01 $26,750 $30.00 $24,390.01 $26,390 $25,570.01 $27,570 $26,750.01 $28,750 $35.00 $26,390.01 $28,390 $27,570.01 $29,570 $28,750.01 $30,750 $40.00 $28,390.01 $30,390 $29,570.01 $31,570 $30,750.01 $32,750 $45.00 $30,390.01 $32,390 $31,570.01 $33,570 $32,750.01 $34,750 $50.00 $32,390.01 $34,390 $33,570.01 $35,570 $34,750.01 $36,750 $55.00 $34,390.01 $36,390 $35,570.01 $37,570 $36,750.01 $38,750 $60.00 $36,390.01 $38,390 $37,570.01 $39,570 $38,750.01 $40,750 $65.00 $38,390.01 $40,390 $39,570.01 $41,570 $40,750.01 $42,750 $70.00 $40,390.01 $42,390 $41,570.01 $43,570 $42,750.01 $44,750 $75.00 $42,390.01 $44,390 $43,570.01 $45,570 $44,750.01 $46,750 $80.00 $44,390.01 $46,390 $45,570.01 $47,570 $46,750.01 $48,750 $85.00 $46,390.01 $48,390 $47,570.01 $49,570 $48,750.01 $50,750 $90.00 $48,390.01 $50,390 $49,570.01 $51,570 $50,750.01 $52,750 $95.00 $50,390.01 $52,390 $51,570.01 $53,570 $52,750.01 $54,750 $100.00 $52,390.01 $54,390 $53,570.01 $55,570 $54,750.01 $56,750 $105.00 $54,390.01 56,390 $55,570.01 $57,570 $56,750.01 $58,750 $110.00 $56,390.01 $58,390 $57,570.01 $59,570 $58,750.01 $60,750 $115.00 $58,390.01 $60,390 $59,570.01 $61,570 $60,750.01 $62,750 $120.00 $60,390.01 $62,390 $61,570.01 $63,570 $62,750.01 $64,750 $125.00 $62,390.01 $64,390 $63,570.01 $65,570 $64,750.01 $66,750 $130.00 $64,390.01 $66,390 $65,570.01 $67,570 $66,750.01 $68,750 $135.00 $66,390.01 $66,717 $67,570.01 $69,570 $68,750.01 $70,750 $140.00 $69,570.01 $71,570 $70,750.01 $72,750 $145.00 $71,570.01 $73,570 $72,750.01 $74,750 $150.00 $73,570.01 $74,190 $74,750.01 $76,750 $155.00 $76,750.01 $78,750 $160.00 $78,750.01 $80,750 $165.00 $80,750.01 $81,663 200% FPIG $56,780 200% FPIG $63,140 200% FPIG $69,500
Weekly Family Size: 10 Family Size: 11 Family Size: 12 Co-pay Annual Income Annual Income Annual Income $5.00 Less than: $19,930 Less than: $21,110 Less than: $22,290 $10.00 $19,930.01 $21,930 $21,110.01 $23,110 $22,290.01 $24,290 $15.00 $21,930.01 $23,930 $23,110.01 $25,110 $24,290.01 $26,290 $20.00 $23,930.01 $25,930 $25,110.01 $27,110 $26,290.01 $28,290 $25.00 $25,930.01 $27,930 $27,110.01 $29,110 $28,290.01 $30,290 $30.00 $27,930.01 $29,930 $29,110.01 $31,110 $30,290.01 $32,290 $35.00 $29,930.01 $31,930 $31,110.01 $33,110 $32,290.01 $34,290 $40.00 $31,930.01 $33,930 $33,110.01 $35,110 $34,290.01 $36,290 $45.00 $33,930.01 $35,930 $35,110.01 $37,110 $36,290.01 $38,290 $50.00 $35,930.01 $37,930 $37,110.01 $39,110 $38,290.01 $40,290 $55.00 $37,930.01 $39,930 $39,110.01 $41,110 $40,290.01 $42,290 $60.00 $39,930.01 $41,930 $41,110.01 $43,110 $42,290.01 $44,290 $65.00 $41,930.01 $43,930 $43,110.01 $45,110 $44,290.01 $46,290 $70.00 $43,930.01 $45,930 $45,110.01 $47,110 $46,290.01 $48,290 $75.00 $45,930.01 $47,930 $47,110.01 $49,110 $48,290.01 $50,290 $80.00 $47,930.01 $49,930 $49,110.01 $51,110 $50,290.01 $52,290 $85.00 $49,930.01 $51,930 $51,110.01 $53,110 $52,290.01 $54,290 $90.00 $51,930.01 $53,930 $53,110.01 $55,110 $54,290.01 56,290 $95.00 $53,930.01 $55,930 $55,110.01 $57,110 $56,290.01 $58,290 $100.00 $55,930.01 $57,930 $57,110.01 $59,110 $58,290.01 $60,290 $105.00 $57,930.01 $59,930 $59,110.01 $61,110 $60,290.01 $62,290 $110.00 $59,930.01 $61,930 $61,110.01 $63,110 $62,290.01 $64,290 $115.00 $61,930.01 $63,930 $63,110.01 $65,110 $64,290.01 $66,290 $120.00 $63,930.01 $65,930 $65,110.01 $67,110 $66,290.01 $68,290 $125.00 $65,930.01 $67,930 $67,110.01 $69,110 $68,290.01 $70,290 $130.00 $67,930.01 $69,930 $69,110.01 $71,110 $70,290.01 $72,290 $135.00 $69,930.01 $71,930 $71,110.01 $73,110 $72,290.01 $74,290 $140.00 $71,930.01 $73,930 $73,110.01 $75,110 $74,290.01 $76,290 $145.00 $73,930.01 $75,930 $75,110.01 $77,110 $76,290.01 $78,290 $150.00 $75,930.01 $77,930 $77,110.01 $79,110 $78,290.01 $80,290 $155.00 $77,930.01 $79,930 $79,110.01 $81,110 $80,290.01 $82,290 $160.00 $79,930.01 $81,930 $81,110.01 $83,110 $82,290.01 $84,290 $165.00 $81,930.01 $83,930 $83,110.01 $85,110 $84,290.01 $86,290 $170.00 $83,930.01 $85,930 $85,110.01 $87,110 $86,290.01 $88,290 $175.00 $85,930.01 $87,930 $87,110.01 $89,110 $88,290.01 $90,290 $180.00 $87,930.01 $89,136 $89,110.01 $91,110 $90,290.01 $92,290 $185.00 $91,110.01 $93,110 $92,290.01 $94,290 $190.00 $93,110.01 $95,110 $94,290.01 $96,290 $195.00 $95,110.01 $96,609 $96,290.01 $98,290 $200.00 $98,290.01 $100,290 $205.00 $100,290.01 $102,290 $210.00 $102,290.01 $104,082 200% FPIG $75,860 200% FPIG $82,220 200% FPIG $88,580
Weekly Family Size: 13 Family Size: 14 Family Size: 15 Co-pay Annual Income Annual Income Annual Income $5.00 Less than: $23,470 Less than: $24,650 Less than: $25,830 $10.00 $23,470.01 $25,470 $24,650.01 $26,650 $25,830.01 $27,830 $15.00 $25,470.01 $27,470 $26,650.01 $28,650 $27,830.01 $29,830 $20.00 $27,470.01 $29,470 $28,650.01 $30,650 $29,830.01 $31,830 $25.00 $29,470.01 $31,470 $30,650.01 $32,650 $31,830.01 $33,830 $30.00 $31,470.01 $33,470 $32,650.01 $34,650 $33,830.01 $35,830 $35.00 $33,470.01 $35,470 $34,650.01 $36,650 $35,830.01 $37,830 $40.00 $35,470.01 $37,470 $36,650.01 $38,650 $37,830.01 $39,830 $45.00 $37,470.01 $39,470 $38,650.01 $40,650 $39,830.01 $41,830 $50.00 $39,470.01 $41,470 $40,650.01 $42,650 $41,830.01 $43,830 $55.00 $41,470.01 $43,470 $42,650.01 $44,650 $43,830.01 $45,830 $60.00 $43,470.01 $45,470 $44,650.01 $46,650 $45,830.01 $47,830 $65.00 $45,470.01 $47,470 $46,650.01 $48,650 $47,830.01 $49,830 $70.00 $47,470.01 $49,470 $48,650.01 $50,650 $49,830.01 $51,830 $75.00 $49,470.01 $51,470 $50,650.01 $52,650 $51,830.01 $53,830 $80.00 $51,470.01 $53,470 $52,650.01 $54,650 $53,830.01 $55,830 $85.00 $53,470.01 $55,470 $54,650.01 $56,650 $55,830.01 $57,830 $90.00 $55,470.01 $57,470 $56,650.01 $58,650 $57,830.01 $59,830 $95.00 $57,470.01 $59,470 $58,650.01 $60,650 $59,830.01 $61,830 $100.00 $59,470.01 $61,470 $60,650.01 $62,650 $61,830.01 $63,830 $105.00 $61,470.01 $63,470 $62,650.01 $64,650 $63,830.01 $65,830 $110.00 $63,470.01 $65,470 $64,650.01 $66,650 $65,830.01 $67,830 $115.00 $65,470.01 $67,470 $66,650.01 $68,650 $67,830.01 $69,830 $120.00 $67,470.01 $69,470 $68,650.01 $70,650 $69,830.01 $71,830 $125.00 $69,470.01 $71,470 $70,650.01 $72,650 $71,830.01 $73,830 $130.00 $71,470.01 $73,470 $72,650.01 $74,650 $73,830.01 $75,830 $135.00 $73,470.01 $75,470 $74,650.01 $76,650 $75,830.01 $77,830 $140.00 $75,470.01 $77,470 $76,650.01 $78,650 $77,830.01 $79,830 $145.00 $77,470.01 $79,470 $78,650.01 $80,650 $79,830.01 $81,830 $150.00 $79,470.01 $81,470 $80,650.01 $82,650 $81,830.01 $83,830 $155.00 $81,470.01 $83,470 $82,650.01 $84,650 $83,830.01 $85,830 $160.00 $83,470.01 $85,470 $84,650.01 $86,650 $85,830.01 $87,830 $165.00 $85,470.01 $87,470 $86,650.01 $88,650 $87,830.01 $89,830 $170.00 $87,470.01 $89,470 $88,650.01 $90,650 $89,830.01 $91,830 $175.00 $89,470.01 $91,470 $90,650.01 $92,650 $91,830.01 $93,830 $180.00 $91,470.01 $93,470 $92,650.01 $94,650 $93,830.01 $95,830 $185.00 $93,470.01 $95,470 $94,650.01 $96,650 $95,830.01 $97,830 $190.00 $95,470.01 $97,470 $96,650.01 $98,650 $97,830.01 $99,830 $195.00 $97,470.01 $99,470 $98,650.01 $100,650 $99,830.01 $101,830 $200.00 $99,470.01 $101,470 $100,650.01 $102,650 $101,830.01 $103,830 $205.00 $101,470.01 $103,470 $102,650.01 $104,650 $103,830.01 $105,830 $210.00 $103,470.01 $105,470 $104,650.01 $106,650 $105,830.01 $107,830 $215.00 $105,470.01 $107,470 $106,650.01 $108,650 $107,830.01 $109,830 $220.00 $107,470.01 $109,470 $108,650.01 $110,650 $109,830.01 $111,830 $225.00 $109,470.01 $111,470 $110,650.01 $112,650 $111,830.01 $113,830 $230.00 $111,470.01 $111,555 $112,650.01 $114,650 $113,830.01 $115,830 $235.00 $114,650.01 $116,650 $115,830.01 $117,830 $240.00 $116,650.01 $118,650 $117,830.01 $119,830 $245.00 $118,650.01 $119,028 $119,830.01 $121,830 $250.00 $121,830.01 $123,830 $255.00 $123,830.01 $125,830 $260.00 $125,830.01 $126,501 200% FPIG $94,940 200% FPIG $101,300 200% FPIG $107,660
Weekly Family Size: 16 Family Size: 17 Family Size: 18 Co-pay Annual Income Annual Income Annual Income $5.00 Less than: $29,010 Less than: $30,190 Less than: $31,370 $10.00 $29,010.01 $31,010 $30,190.01 $32,190 $31,370.01 $33,370 $15.00 $31,010.01 $33,010 $32,190.01 $34,190 $33,370.01 $35,370 $20.00 $33,010.01 $35,010 $34,190.01 $36,190 $35,370.01 $37,370 $25.00 $35,010.01 $37,010 $36,190.01 $38,190 $37,370.01 $39,370 $30.00 $37,010.01 $39,010 $38,190.01 $40,190 $39,370.01 $41,370 $35.00 $39,010.01 $41,010 $40,190.01 $42,190 $41,370.01 $43,370 $40.00 $41,010.01 $43,010 $42,190.01 $44,190 $43,370.01 $45,370 $45.00 $43,010.01 $45,010 $44,190.01 $46,190 $45,370.01 $47,370 $50.00 $45,010.01 $47,010 $46,190.01 $48,190 $47,370.01 $49,370 $55.00 $47,010.01 $49,010 $48,190.01 $50,190 $49,370.01 $51,370 $60.00 $49,010.01 $51,010 $50,190.01 $52,190 $51,370.01 $53,370 $65.00 $51,010.01 $53,010 $52,190.01 $54,190 $53,370.01 $55,370 $70.00 $53,010.01 $55,010 $54,190.01 $56,190 $55,370.01 $57,370 $75.00 $55,010.01 $57,010 $56,190.01 $58,190 $57,370.01 $59,370 $80.00 $57,010.01 $59,010 $58,190.01 $60,190 $59,370.01 $61,370 $85.00 $59,010.01 $61,010 $60,190.01 $62,190 $61,370.01 $63,370 $90.00 $61,010.01 $63,010 $62,190.01 $64,190 $63,370.01 $65,370 $95.00 $63,010.01 $65,010 $64,190.01 $66,190 $65,370.01 $67,370 $100.00 $65,010.01 $67,010 $66,190.01 $68,190 $67,370.01 $69,370 $105.00 $67,010.01 $69,010 $68,190.01 $70,190 $69,370.01 $71,370 $110.00 $69,010.01 $71,010 $70,190.01 $72,190 $71,370.01 $73,370 $115.00 $71,010.01 $73,010 $72,190.01 $74,190 $73,370.01 $75,370 $120.00 $73,010.01 $75,010 $74,190.01 $76,190 $75,370.01 $77,370 $125.00 $75,010.01 $77,010 $76,190.01 $78,190 $77,370.01 $79,370 $130.00 $77,010.01 $79,010 $78,190.01 $80,190 $79,370.01 $81,370 $135.00 $79,010.01 $81,010 $80,190.01 $82,190 $81,370.01 $83,370 $140.00 $81,010.01 $83,010 $82,190.01 $84,190 $83,370.01 $85,370 $145.00 $83,010.01 $85,010 $84,190.01 $86,190 $85,370.01 $87,370 $150.00 $85,010.01 $87,010 $86,190.01 $88,190 $87,370.01 $89,370 $155.00 $87,010.01 $89,010 $88,190.01 $90,190 $89,370.01 91,370 $160.00 $89,010.01 $91,010 $90,190.01 $92,190 $91,370.01 $93,370 $165.00 $91,010.01 $93,010 $92,190.01 $94,190 $93,370.01 $95,370 $170.00 $93,010.01 $95,010 $94,190.01 $96,190 $95,370.01 $97,370 $175.00 $95,010.01 $97,010 $96,190.01 $98,190 $97,370.01 $99,370 $180.00 $97,010.01 $99,010 $98,190.01 $100,190 $99,370.01 $101,370 $185.00 $99,010.01 $101,010 $100,190.01 $102,190 $101,370.01 $103,370 $190.00 $101,010.01 $103,010 $102,190.01 $104,190 $103,370.01 $105,370 $195.00 $103,010.01 $105,010 $104,190.01 $106,190 $105,370.01 $107,370 $200.00 $105,010.01 $107,010 $106,190.01 $108,190 $107,370.01 $109,370 $205.00 $107,010.01 $109,010 $108,190.01 $110,190 $109,370.01 $111,370 $210.00 $109,010.01 $111,010 $110,190.01 $112,190 $111,370.01 $113,370 $215.00 $111,010.01 $113,010 $112,190.01 $114,190 $113,370.01 $115,370 $220.00 $113,010.01 $115,010 $114,190.01 $116,190 $115,370.01 $117,370 $225.00 $115,010.01 $117,010 $116,190.01 $118,190 $117,370.01 $119,370 $230.00 $117,010.01 $119,010 $118,190.01 $120,190 $119,370.01 $121,370 $235.00 $119,010.01 $121,010 $120,190.01 $122,190 $121,370.01 $123,370 $240.00 $121,010.01 $123,010 $122,190.01 $124,190 $123,370.01 $125,370 $245.00 $123,010.01 $125,010 $124,190.01 $126,190 $125,370.01 $127,370 $250.00 $125,010.01 $127,010 $126,190.01 $128,190 $127,370.01 $129,370 $255.00 $127,010.01 $129,010 $128,190.01 $130,190 $129,370.01 $131,370 $260.00 $129,010.01 $131,010 $130,190.01 $132,190 $131,370.01 $133,370 $265.00 $131,010.01 $133,010 $132,190.01 $134,190 $133,370.01 $135,370 $270.00 $133,010.01 $133,974 $134,190.01 $136,190 $135,370.01 $137,370 $275.00 $136,190.01 $138,190 $137,370.01 $139,370 $280.00 $138,190.01 $140,190 $139,370.01 $141,370 $285.00 $140,190.01 $141,447 $141,370.01 $143,370 $290.00 $143,370.01 $145,370 $295.00 $145,370.01 $147,370 $300.00 $147,370.01 $148,920 200% FPIG $114,020 200% FPIG $120,380 200% FPIG $126,740
Weekly Family Size: 19 Family Size: 20 Family Size: 21 Co-pay Annual Income Annual Income Annual Income $5.00 Less than: $32,550 Less than: $33,730 Less than: $34,910 $10.00 $32,550.01 $34,550 $33,730.01 $35,730 $34,910.01 $36,910 $15.00 $34,550.01 $36,550 $35,730.01 $37,730 $36,910.01 $38,910 $20.00 $36,550.01 $38,550 $37,730.01 $39,730 $38,910.01 $40,910 $25.00 $38,550.01 $40,550 $39,730.01 $41,730 $40,910.01 $42,910 $30.00 $40,550.01 $42,550 $41,730.01 $43,730 $42,910.01 $44,910 $35.00 $42,550.01 $44,550 $43,730.01 $45,730 $44,910.01 $46,910 $40.00 $44,550.01 $46,550 $45,730.01 $47,730 $46,910.01 $48,910 $45.00 $46,550.01 $48,550 $47,730.01 $49,730 $48,910.01 $50,910 $50.00 $48,550.01 $50,550 $49,730.01 $51,730 $50,910.01 $52,910 $55.00 $50,550.01 $52,550 $51,730.01 $53,730 $52,910.01 $54,910 $60.00 $52,550.01 $54,550 $53,730.01 $55,730 $54,910.01 $56,910 $65.00 $54,550.01 $56,550 $55,730.01 $57,730 $56,910.01 $58,910 $70.00 $56,550.01 $58,550 $57,730.01 $59,730 $58,910.01 $60,910 $75.00 $58,550.01 $60,550 $59,730.01 $61,730 $60,910.01 $62,910 $80.00 $60,550.01 $62,550 $61,730.01 $63,730 $62,910.01 $64,910 $85.00 $62,550.01 $64,550 $63,730.01 $65,730 $64,910.01 $66,910 $90.00 $64,550.01 $66,550 $65,730.01 $67,730 $66,910.01 $68,910 $95.00 $66,550.01 $68,550 $67,730.01 $69,730 $68,910.01 $70,910 $100.00 $68,550.01 $70,550 $69,730.01 $71,730 $70,910.01 $72,910 $105.00 $70,550.01 $72,550 $71,730.01 $73,730 $72,910.01 $74,910 $110.00 $72,550.01 $74,550 $73,730.01 $75,730 $74,910.01 $76,910 $115.00 $74,550.01 $76,550 $75,730.01 $77,730 $76,910.01 $78,910 $120.00 $76,550.01 $78,550 $77,730.01 $79,730 $78,910.01 $80,910 $125.00 $78,550.01 $80,550 $79,730.01 $81,730 $80,910.01 $82,910 $130.00 $80,550.01 $82,550 $81,730.01 $83,730 $82,910.01 $84,910 $135.00 $82,550.01 $84,550 $83,730.01 $85,730 $84,910.01 $86,910 $140.00 $84,550.01 $86,550 $85,730.01 $87,730 $86,910.01 $88,910 $145.00 $86,550.01 $88,550 $87,730.01 $89,730 $88,910.01 $90,910 $150.00 $88,550.01 $90,550 $89,730.01 $91,730 $90,910.01 $92,910 $155.00 $90,550.01 $92,550 $91,730.01 $93,730 $92,910.01 $94,910 $160.00 $92,550.01 $94,550 $93,730.01 $95,730 $94,910.01 $96,910 $165.00 $94,550.01 $96,550 $95,730.01 $97,730 $96,910.01 $98,910 $170.00 $96,550.01 $98,550 $97,730.01 $99,730 $98,910.01 $100,910 $175.00 $98,550.01 $100,550 $99,730.01 $101,730 $100,910.01 $102,910 $180.00 $100,550.01 $102,550 $101,730.01 $103,730 $102,910.01 $104,910 $185.00 $102,550.01 $104,550 $103,730.01 $105,730 $104,910.01 $106,910 $190.00 $104,550.01 $106,550 $105,730.01 $107,730 $106,910.01 $108,910 $195.00 $106,550.01 $108,550 $107,730.01 $109,730 $108,910.01 $110,910 $200.00 $108,550.01 $110,550 $109,730.01 $111,730 $110,910.01 $112,910 205.00 $110,550.01 $112,550 $111,730.01 $113,730 $112,910.01 $114,910 $210.00 $112,550.01 $114,550 $113,730.01 $115,730 $114,910.01 $116,910 $215.00 $114,550.01 $116,550 $115,730.01 $117,730 $116,910.01 $118,910 $220.00 $116,550.01 $118,550 $117,730.01 $119,730 $118,910.01 $120,910 $225.00 $118,550.01 $120,550 $119,730.01 $121,730 $120,910.01 $122,910 $230.00 $120,550.01 $122,550 $121,730.01 $123,730 $122,910.01 $124,910 $235.00 $122,550.01 $124,550 $123,730.01 $125,730 $124,910.01 $126,910 $240.00 $124,550.01 $126,550 $125,730.01 $127,730 $126,910.01 $128,910 $245.00 $126,550.01 $128,550 $127,730.01 $129,730 $128,910.01 $130,910 $250.00 $128,550.01 $130,550 $129,730.01 $131,730 $130,910.01 $132,910 $255.00 $130,550.01 $132,550 $131,730.01 $133,730 $132,910.01 $134,910 $260.00 $132,550.01 $134,550 $133,730.01 $135,730 $134,910.01 $136,910 $265.00 $134,550.01 $136,550 $135,730.01 $137,730 $136,910.01 $138,910 $270.00 $136,550.01 $138,550 $137,730.01 $139,730 $138,910.01 $140,910 $275.00 $138,550.01 $140,550 $139,730.01 $141,730 $140,910.01 $142,910 $280.00 $140,550.01 $142,550 $141,730.01 $143,730 $142,910.01 $144,910 $285.00 $142,550.01 $144,550 $143,730.01 145,730 $144,910.01 $146,910 $290.00 $144,550.01 $146,550 $145,730.01 $147,730 $146,910.01 $148,910 $295.00 $146,550.01 $148,550 $147,730.01 $149,730 $148,910.01 $150,910 $300.00 $148,550.01 $150,550 $149,730.01 $151,730 $150,910.01 $152,910 $305.00 $150,550.01 $152,550 $151,730.01 $153,730 $152,910.01 $154,910 $310.00 $152,550.01 $154,550 $153,730.01 $155,730 $154,910.01 $156,910 $315.00 $154,550.01 $156,393 $155,730.01 $157,730 $156,910.01 $158,910 $320.00 $157,730.01 $159,730 $158,910.01 $160,910 $325.00 $159,730.01 $161,730 $160,910.01 $162,910 $330.00 $161,730.01 $163,730 $162,910.01 $164,910 $335.00 $163,730.01 $163,866 $164,910.01 $166,910 $340.00 $166,910.01 $168,910 $345.00 $168,910.01 $170,910 $350.00 $170,910.01 $171,339 200% FPIG $133,100 200% FPIG $139,460 200% FPIG $145,820
[Pa.B. Doc. No. 04-1687. Filed for public inspection September 10, 2004, 9:00 a.m.]
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