Mc 326 C Supplemental Security Income (Ssi) Income Work Sheet-Eligible Child printable pdf download

State of California—Health and Welfare Agency

Department of Health Care Services

SUPPLEMENTAL SECURITY INCOME (SSI) METHODOLOGY

INCOME WORK SHEET—ELIGIBLE CHILD

WITH INELIGIBLE PARENT OR PARENT(S)

Case name

Case number

Applicant’s name

PART I. INELIGIBLE PARENT’S UNEARNED INCOME (INCLUDE STEPPARENTS)

1. Parent’s unearned income—do not include public assistance (PA), other PA parent’s income.

Do not include parent’s income if spouse is PA or other PA:

$ ____________

2. Allocation for ineligible children (if no children, enter zero in Part I.2.c.). Do not include applicant or

eligible children for this program.

CHILD NUMBER 1

CHILD NUMBER 2

CHILD NUMBER 3 CHILD NUMBER 4

Name

a. Standard SSI allocation (Federal Benefit Rate

[FBR] for a couple minus FBR for an individual):

b. Minus child’s income

(evaluate for student deduction)

—

c. Total allocation:

_________

+ ________

+ ________ = $ _____________

3. Remaining unearned income (subtract line I.2.c. from line I.1.):

$ _____________

PART II. INELIGIBLE PARENT’S EARNED INCOME (INCLUDE STEPPARENTS)

1. Parent’s gross earned income: ............................................................................................................................... $ _____________

2. Unused portion of allocation for ineligible child(ren): .............................................................................................. $ _____________

3. Remaining earned income (subtract II.2. from II.1.): .............................................................................................. $ _____________

IF THERE IS NO INCOME REMAINING AND I.3 AND II.3. ARE BOTH ZERO, DO NOT DEEM, GO TO PART IV.

IF THERE IS INCOME, PROCEED WITH PART III.

PART III. COMBINED INCOMES—Ineligible Parents

PART IV. ELIGIBILITY CALCULATION

Unearned Income

1. Deemed income from Part III.15.

1. Remaining unearned income (after allocation) or zero (from I.3.)

2. Eligible child’s own OASDI income

2. A. Subtract general income exclusion

–

3. Other unearned income

B. Subtract other unearned income deductions

–

4. A. Subtract general income exclusion

–

3. Countable unearned income (to III.11.)

B. Subtract other unearned income deductions

–

Earned Income

5. Countable unearned income (IV.1. + IV.2. + IV.3. – $20)

4. Remaining earned income (from II.3.)

6. A. Child’s countable earned income (subtract $65 +

remainder)

–

1/2

5. Subtract balance of general income exclusion

B. Subtract other earned income deductions (e.g., impairment-related

work expenses, blind work expenses)

–

6. Remainder

7. Total countable income

7. A. Subtract work expense exclusion

–

8. Current SSI/SSP income standard

B. Subtract other earned income deductions

–

If line IV-7 is less than or equal to line IV.8., this person is income eligible.

8. Remainder

9. Subtract

remainder

1/2

10. Countable earned income (to III.12.)

Deemed Income

11. Countable unearned income (from III.3.)

12. Add countable earned income (from III.10.)

13. Total countable income (from III.11. + III.12.)

14. Subtract parent deduction*

–

15. Deemed income. Enter on Line IV.1.

* Individual FBR if one ineligible parent lives with child; couple FBR if both ineligible parents live with child.

MC 326 C (05/07)

Mc 326 C Supplemental Security Income (Ssi) Income Work Sheet-Eligible Child

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