Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 15
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34Person 3 (continued)
STEP 2
|
otHER iNCoME
30. Check all that apply, and give the amount and how often this person gets it. If this person receives a one-time payment, please
include the month in which it was received. NotE: you do not need to tell us about child support, nontaxable veteran’s
payments, Supplemental Security income (SSi), or most workers’ compensation.
Social security benefits $
How often/month received?
Unemployment $
How often/month received?
Retirement or pension $
How often/month received?
Source
Capital gains $
How often/month received?
Interest, dividends, and other Investment income $
How often/month received?
Net rental or royalty income $
How often/month received?
Net farming or fishing income $
How often/month received?
Alimony received $
How often/month received?
Other taxable income $
How often/month received?
Type
DEDUCtioNS
31. Check all that apply. Give the amount and how often this person gets it.
If this person pays for certain things that can be deducted on a federal income tax return, telling us about them could make the
cost of health coverage a little lower. NotE: Do not include a cost already considered in the answers to net self-employment
income, net rental or royalty income, or net farming or fishing income.
Alimony paid $
How often?
Student loan interest $
How often?
Other tax deductions (educator expenses; certain business expenses of reservists, performing artists, or fee-based
government officials; health savings account deduction; moving expenses; deductible part of self-employment tax;
contribution to self-employed SEP, SIMPLE, and qualified plans; self-employed health insurance deduction; penalty on early
withdrawal of savings; Individual Retirement Account (IRA) deduction; higher education tuition and fees; and domestic
production activities deduction). Enter the amount up to the maximum deductible allowed by the IRS. Do not include any
type of deduction that is not listed above.
Type
$
How often?
yEARly iNCoME
32. What is this person's total expected income for the current calendar year?
33. What is this person's total expected income for next calendar year, if different?
THANKS! This is all we need to know about this person. Go to Step 2 Person 4 to add another household member, if needed.
Otherwise, go to Step 3 American Indian or Alaska Native (AI/AN) Household Member(s).
Page 13
ACA-3 (Rev. 10/16)
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