Form Mc 210 S-W - Vocational And Work History Form Page 2
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1
2State of California--Health and Human Services Agency
Department of Health Care Services
MEDI-CAL U-PARENT DETERMINATION WORKSHEET
(To Be Completed By CWD Staff)
Case name: ______________________________________________
Worker number: _________________________
Case number:_____________________________________________
Date: __________________________________
1. Determination of Principal Wage Earner (PWE)
a. Application date OR date U-Parent deprivation began: ____________
b. To establish 24-month earnings period, check month on chart for each parent:
Month number 1:
subtract two years from line (a): ______________
Month number 24: Month/Year immediately preceding line (a): ______________
Current year ___________
Year __________
Year __________
Parent 1’s Earnings
$
Dec.
$
Dec.
$
Dec.
COU
NTY
$
Nov.
$
Nov.
$
Nov.
$
Oct.
$
Oct.
$
Oct.
__________________
$
Sep.
$
Sep.
$
Sep.
Name
$
Aug.
$
Aug.
$
Aug.
$
Jul.
$
Jul.
$
Jul.
$
Jun.
$
Jun.
$
Jun.
$
May
$
May
$
May
$
Apr.
$
Apr.
$
Apr.
U
SE
$
Mar.
$
Mar.
$
Mar.
$
Feb.
$
Feb.
$
Feb.
Total: $_____________
$
Jan.
$
Jan.
$
Jan.
Current year ___________
Year __________
Year __________
Parent 2’s Earnings
$
Dec.
$
Dec.
$
Dec.
$
Nov.
$
Nov.
$
Nov.
$
Oct.
$
Oct.
$
Oct.
__________________
ON
LY
$
Sep.
$
Sep.
$
Sep.
Name
$
Aug.
$
Aug.
$
Aug.
$
Jul.
$
Jul.
$
Jul.
$
Jun.
$
Jun.
$
Jun.
$
May
$
May
$
May
$
Apr.
$
Apr.
$
Apr.
$
Mar.
$
Mar.
$
Mar.
$
Feb.
$
Feb.
$
Feb.
Total: $_____________
$
Jan.
$
Jan.
$
Jan.
The parent earning the greater amount is the PWE: _______________________________________________________
(Name of PWE)
❒ Yes
❒ No
2. Is the PWE working 100 hours or more a month?
If “yes,” complete the Unemployed Parent Worksheet (MC 337).
Note:
If the PWE is a recipient of Section 1931(b), he/she may exceed 100 hours with no earned income test.
Page 2 of 2
MC 210 S-W (05/07)
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