100% Federal Poverty Level

The following figures are used for:

·   Form DA-3M

·   Side 1 of Form DA-4M

·   School Age Medical (SAM).

Family Size

Monthly Income

1

$931

2

1,261

3

1,591

4

1,921

5

2,251

6

2,581

7

2,911

8

3,241

9

3,571

10

3,901

11

4,231

12

4,561

{Rev. 1/1/12}