INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FDL) AND CHILDREN'S HEALTH INSURANCE PROGRAM APPLICATION (CHIP) (Form PEEHIP FPL & CHIP)

To apply for federal poverty level assistance or the state administered children's health insurance program while working as an Alabama public education employee, use the application discussed in this article. This document can be obtained from the website of the Retirement Systems of Alabama.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 1: Indicate with a check mark whether you are applying for FDL, CHIP or both.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 2: The first section concerns the public employee subscriber. On the first line, enter your Social Security number, first name, middle name or initial and last name.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 3: On the second line, enter the subscriber's mailing address, city, state and zip code.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 4: On the third line, enter the subscriber's home phone number and work phone number.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 5: Indicate your marital status with a check mark.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 6: The next section is for CHIP applicants. Indicate whether any child is covered under Medicaid with a check mark. If yes, give the names of the eligible children.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 7: Document all household members where indicated. Provide their name, Social Security number, date of birth, age, sex and relationship to you. Enter your information on line A, that of your spouse on line B, and those of all dependents under 19 years of age living in your home on lines C through F.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 8: Answer all remaining questions with check marks, then sign and date the bottom of the page.