ARE YOU A NEW PEDIATRICS PATIENT TO SHF?  
SELECT THE SHF SERVICES YOU CURRENTLY ACCESS FOR PEDIATRICS  

SHF REGISTRATION UPDATE ONLY

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DID PARENT FILE TAXES LAST YEAR?  
MODIFIED ADJUSTED GROSS INCOME WORKSHEET (INCOME TAX FILERS) 
 DOLLAR ($$)
(+) Adjusted Gross Income - Form 1040EZ - Line 4
(+) Adjusted Gross Income - Form 1040A - Line 21
(+) Adjusted Gross Income - Form 1040 - Line 37
(+) Non-Taxable SS Benefits - Form 1040 - Line 20a-20b
(+) Non-Taxable SS Benefits - Form 1040A - Line 14a-14b
(+) Tax-exempt Interest - Form 1040 - Line 8b
(+) Foreign Earned Income - Form 2555
(-) Income - Scholarships, Grants, Awards
(-) Certain Income Native America
(-) Lump sum received for 1 month
Modified Adjusted Gross Income (MAGI) =
MODIFIED ADJUSTED GROSS INCOME WORKSHEET (NO TAX RETURNS FILED) 
 DOLLAR ($$)
(+) Wages, Salaries, Tips, etc
(+) Taxable Interest
(+) Tax Exempt Interest
(+) IRA Distributions - Taxable Amount
(+) Pensions & Annuities
(+) Retirement Income from SSA
(+) Disability Income SSDI
(+) Non-taxable Social Security Benefits
(+) Business Income (or loss)
(+) Farm Income (or loss)
(+) Capital Gain (or loss)
(+) Other Gains (or losses)
(+) Unemployment Income
(+) Ordinary Dividends
(+) Alimony or other Spousal Support Received
(+) Rental Real Estate, S Corporations
(+) Taxable Refunds / Credits - State Income Tax
(+) Other Income (Jury Duty Pay, Gambling Winnings)
(+) Foreign Earned Income & Housing Living Abroad
(-) Deductible Part of Self Employment Tax
(-) Self Employed SEP, Simple Gains
(-) Self-Employment Health Insurance Deductions
(-) Student Loan Interest Deduction
(-) Tuition and Fees
(-) Scholarships, Awards, Fellowships Grants
(-) Educator Expenses
(-) IRA Deduction
(-) Moving Expenses
(-) Penalty on Early Withdrawal of Savings
(-) Health Savings Account
(-) Alimony Paid
(-) Domestic Production Activities
(-) Business Expenses
(-) Certain American Indian Income
(-) Amount Received As a Lump Sum (not monthly)
MODIFIED ADJUSTED GROSS INCOME

EMERGENCY CONTACT UPDATE

HAVE YOU INFORMED THIS PERSON YOU ARE RECEIVING SERVICES FROM SHF? (UPD) 

UPDATED PROOF OF RESIDENCE AND INCOME




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