INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL) (Form 2G)

Alabama public education employees who have a combined family income less than or equal to 200% of the Federal Poverty Level may apply for assistance. To do so, they must be enrolled in the state's Public Education Employees' Health Insurance Plan. Form 2G, used to request assistance, is located on the website of the Retirement Systems of Alabama. This document can also be used to request children's health insurance.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 1: The first section concerns subscriber information. Enter your Social Security number and name on the first line.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 2: On the second line, enter your mailing address, city, state and zip code.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 3: On the third line, enter your home and work phone numbers.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 4: On the fourth line, indicate whether you are married, single, divorced, legally separated or widowed with a check mark.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 5: The next section is only for those seeking children's health insurance. Indicate with a check mark whether any children are enrolled in Medicaid. If yes, give their names.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 6: A table is provided to list all household members. On line A of the first column, enter the name of the subscriber. On line B, enter the name of their spouse. On lines C through F, list all children under age 19 living in your household.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 7: In the second column, provide all listed household members' Social Security numbers.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 8: In the third column, provide all listed household members' dates of birth.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 9: In the fourth column, provide all listed household members' gender.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 10: In the fifth column, describe the relationship to you of all listed household members. Enter your requested effective date and answer all remaining questions as instructed.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 11: Sign and date the form.