Form Dfa 285-D - Calfresh Budget Worksheet - Special Medical/shelter Deductions Page 2
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1
2ISSUANCE
ISSUANCE
PART 4 – INCOME COMPUTATIONS
MONTH
MONTH
I. SELF-EMPLOYMENT
(Nonexempt Resources Only)
1. Gross Income from Self-Employment
$______________
$______________
■ ■
2. Expenses:
Standard 40% Deduction
$______________
$______________
■ ■
Actual Expenses (Verification Required)
3. Total Nonexempt Income from Self-Employment (I1 - I2)
$______________
$______________
If averaging self-employment income go to I7. If adjusting
a previous average, continue to I4.
$______________
$______________
4. Adjustment to Gross Income
5. Adjustment to Expenses
$______________
$______________
6. Adjusted Self-Employment Income (I3 + I4 + I5)
$______________
$______________
7. Monthly Self-Employment Income (I3 or I6 ÷ number of
$______________
$______________
months income covers)
ISSUANCE
ISSUANCE
J. EDUCATIONAL GRANTS, SCHOLARSHIPS AND
MONTH
MONTH
LOANS
1. Income from Grants, Scholarships or Loans
$______________
$______________
2. Tuition and Mandatory Fees
$______________
$______________
$______________
3. Total Nonexempt Educational Income (J1 – J2)
$______________
4. Monthly Income from Grants, Scholarships or Loans
$______________
$______________
(J3 ÷ number of months income covers)
PART 5 – REPORTED CHANGES
(Other than the QR 7 or DFA 377.5)
Type of Change
Date Change
Occurred
Date Change
Reported
EW Initials
DFA 285-D (8/11) REQUIRED FORM - SUBSTITUTES PERMITTED
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