| Item 3 |
- Enter TA 10, Approve and Cancel. |
| Item 28 |
- Enter G. |
| Item 33 |
- Enter TAR 81, Increased Need for Medical Care. |
| Item 41 |
- Enter the last day of the month that the 60-day postpartum period ends. Use a 6-digit date (MMDDYY). |
| Item 60 |
- Enter EDD and the month and year (MMYY) the pregnancy ended. |
| Item 78 |
- Enter P. |
| Item 80 |
- Enter 159 CI. Enter the monthly countable income under AMOUNT. Enter zeroes if there is no countable income. Enter the number included in the Moms and Babies income standard under PERSONS. |