Form Dfa 285-D - Calfresh Budget Worksheet - Special Medical/shelter Deductions
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1
2STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALFRESH BUDGET WORKSHEET –
Special Medical/Shelter Deductions
CLASSIFICATION
CASE NAME
CASE NUMBER
COMPANION CASE REFERENCE
■ ■
■ ■
■ ■
■ ■
NA
PA
MIXED
TC
■ ■
■ ■
CERTIFICATION
PROSPECTIVE
PROSPECTIVE
PERIOD
FROM
THROUGH
DOCUMENTATION
PART 1 – NET MONTHLY INCOME
ISSUANCE
ISSUANCE
MONTH
MONTH
(Gross income test is not applicable to households
with elderly/disabled members)
A. NONEXEMPT GROSS UNEARNED INCOME
____________
____________
$
$
1. Cash Aid
Child/Spousal Support
____________
____________
$
$
2. Social Security, UIB, DIB, Pensions
____________
____________
$
$
3. Child/Spousal Support
Received $____________
____________
____________
$
$
4. Scholarships, Grants, Loans
____________
____________
$
$
Child Support
5. Other
____________
____________
$
$
(Court Ordered)
6. Gross Unearned Income (A1 + A2 + A3 + A4 + A5)
____________
____________
$
$
Paid out total $__________
7. Less Child Support Paid (enter remainder in B6)
___________
___________
8. Total Gross Unearned Income (A6 - A7)
$
$
Total / by number of months
B. NONEXEMPT GROSS EARNED INCOME
____________
____________
$
$
__________
1. Gross Salary, Wages
____________
____________
$
$
2. Self-Employment
____________
____________
$
$
3. Training Allowance
Amount used in A7
____________
____________
$
$
4. Gross Earned Income (B1 + B2 + B3)
$_____________
____________
____________
5. Adjusted Gross Earned Income (80% of B4)
$
$
6. Less Remainder of Child Support Paid (if not fully
Remainder to be used in B6
____________
____________
used in Section A)
$
$
$_____________
7. Total Gross Earned Income (B5 - B6)
___________
___________
$
$
(If negative amount, enter zero)
C. TOTAL NONEXEMPT GROSS INCOME (A8 + B7)
___________
___________
$
$
D. EXCESS MEDICAL EXPENSES
1. Expected Recurring Expenses (occurring during the
Households with an
entire certification period). Include recurring
Elderly/Disabled Member:
averaged expenses.
$ _______________
$ ________________
2. Limited Period Expenses (occurring during only a
portion of the certification period). Include limited
Is the elderly/disabled
____________
____________
$
$
averaged expenses.
member unable to purchase
3. Total Allowable Expenses (D1 + D2)
___________
and prepare meals
$______________
$
4. Less Medical Expense Allowance ($35)
___________
$ ______________
$
separately from others in
5. Excess Medical Expenses (D3 - D4)
___________
___________
$
$
the home due to a
disability?
E. STANDARD/DEPENDENT CARE/MEDICAL/
HOMELESS SHELTER DEDUCTIONS
■ ■
■ ■
___________
Yes
No
___________
$
$
1. Standard Deduction:
___________
___________
$
$
2. Dependent Care (100% of costs)
___________
___________
$
$
3. Excess Medical Expenses (From D5)
If yes, is the household’s
___________
___________
4. Homeless Shelter Deduction
$
$
income (less the elderly and
5. Total Deductions (E1 + E2 +E3 + E4)
___________
___________
$
$
disabled member and
6. Total Adjusted Income (C - E5)
___________
___________
$
$
spouse income) less than
165% of FPL?
F. SHELTER DEDUCTION
____________
____________
■ ■
■ ■
$
$
1. Total Housing Costs
Yes
No
____________
____________
$
$
2. Total Utility Allowance
____________
____________
$
$
3. Total Shelter costs (F1 + F2)
If yes, certify the elderly
____________
____________
$
$
4. Allowable Shelter Costs (50% of E6)
and disabled member (and
___________
___________
$
$
5. Excess Shelter Costs F3-F4
spouse) as a separate
household.
G. NET MONTHLY INCOME (E6–F5)
$
$
PART 2 – NET INCOME ELIGIBILITY
H. NET INCOME TEST
____________
____________
1. Household Size
___________
___________
$
$
2. Maximum Net Income Allowable (From Table)
■ ■
■ ■
■ ■
■ ■
First-Month Benefits
3. Net Income Eligible? (Is G less than or equal to H2?)
YES
NO
YES
NO
Prorated?
■ ■
■ ■
SUPPLEMENT
ALLOTMENT
ALLOTMENT
SUPPLEMENT
Yes
No
PART 3 – BENEFITS
E.W. Initials/Date
DFA 285-D (8/11) REQUIRED FORM - SUBSTITUTES PERMITTED
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