Form Soc 452a - Cash Assistance Program For Immigrants (Capi) - Income Eligibility - Child

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
INCOME ELIGIBILITY – CHILD
Name
Case No.
Month/Year
Parent(s)
Child/Recipient/Applicant
A. Income deemed to a blind or disabled child through the month he or
B. CAPI benefit determination for blind or disabled child who is
1
she reaches age 18 and living with one or both parents.
under age 18 and living with one or both parents
Income of parent and parent’s spouse where
Unearned
Earned
Income of child
Unearned
Earned
neither is a CAPI/SSI recipient
4
1. a. Social Security and other pensions
1. Income deemed to child (from A17)
2. Child’s unearned income (list)
b. Other unearned income
c. Other unearned income
a.
2. Total Unearned income. (Add 1a, b & c)
b.
3. Total gross Earned income
c.
4. Allowance for ineligible children or
3. Total unearned income
2
sponsored CAPI/SSI recipients
(B1 plus B2a, b, & c)
a. Amount
4. General Exclusion
$20
b. Children’s inc.
5. Net Unearned income (B3 minus B4)
c. Net allowance
6. Income based on need (CalWORKs,
(a - b)
VA Pension)
d. Total Allowance (sum of A3c’s)
7. Countable Unearned income
(B5 plus B6)
5. Remaining Unearned income
8. Earned income
(A2 minus A4d)
6. Unused allowance (if A4d is greater than
9. Unused $20 exclusion from above
A2, enter the difference)
7. Remaining Earned income (A3 minus A6)
10. Earned income exclusion
$65
8. General Exclusion
$20
11. Other earned income exclusions
(IRWE, student exclusion)
9. Countable Unearned income
12. Total exclusions
(A5 minus A8)
(Sum of B9, 10 & 11)
10. Unused $20 exclusion from above
13. Subtract B12 from B8, enter result
11. Earned income exclusion
$65
14. Divide B13 by 2, enter result
12. Total exclusions (A10 plus A11)
15. Blind work expenses and remaining
self support plan
13. Earned income (A7 minus A12).
16. Earned countable Income
(B14 minus B15)
14. Divide A13 by 2. Enter result
17. Total countable income
Countable Earned Income
(B7 plus B16)
15. Total countable income (A9 plus A14).
18. CAPI payment level
3
16. Allowance for parent and spouse
19. CAPI payment (B18 minus B17)
1 parent $______________
2 parents $______________
17. Income deemed to child.
(A15 minus A16) (Also enter in B1)
1
If the ineligible parent(s) is receiving assistance based on need,
deeming does not apply and the CAPI payment will be based on the
child’s own income under column B.
3
Allowance for 1 parent = SSI individual standard ($579 in 2005)
2
Ineligible child’s/sponsored recipient allowance equals the difference
Allowance for 2 parents = SSI couple standard ($869 in 2005)
between the federal SSI individual and couple standards ($290 in
4
Note: If more than 1 eligible child, divide deemable income
2005). Sponsored CAPI/SSI recipients (other than child/recipient/
equally among them.
applicant) must have income deemed from ineligible parent(s) and be
.
eligible for CAPI or SSI/SSP
Supervisor’s Signature
Date
Worker
Date
SOC 452A (8/05)

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