STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IHSS INCOME ELIGIBILITY - ADULT
Name ______________________________
Case No. _____________________________
Month/Year __________________________
RECIPIENT
SPOUSE
A.
Income of aged, blind or disabled individual or couple (if individual has
B.
Income of aged, blind or disabled individual and spouse who is not
spouse not aged, blind or disabled, also complete Part B).
aged, blind or disabled.
UNEARNED
EARNED
UNEARNED
EARNED
1. Income of client’s spouse
$
$
1. Unearned income (list)
(Do not show exempt income)
2. Allowance for children not blind or disabled
a.
$
a. Children’s needs
$
$
$
b.
$
b. Children’s income
$
$
$
c.
$
c. Net needs (a -- b)
$
$
$
2. Total unearned income (A1a to A1c)
$
0.00
0.00
d. Total allowance (add B2c’s)
$
3. Any income exclusion
$ 20
3. Remaining unearned income (B1 minus B2d)
$
4. Net unearned income (A2 minus A3)
$
4. Unmet children’s needs (If B2d is greater
5. Earned income (Do not show exempt income)
$
than B1 unearned, enter the difference)
$
6. Unused $20 exclusion (If A3 is greater
5. Remaining earned income (B1 minus B4)
$
than A2, enter the difference)
$
6. Net income of spouse (B3 plus B5)
7. Earned income exclusion
$ 65
-- If equal to or less than
A15 is
65.00
8. Total exclusions (A6 plus A7)
$
entered in C
9. Remaining earned income (A5 minus A8)
$
-- If greater than
complete B7
through B20
$
10. Net earned income (A9 x 1/2)
$
0.00
11. Other earned income deductions
$
7. IHSS client’s income (From A2 and A5)
$
$
12. Total net earned income (A10 minus A11)
$
8. Income of couple (B3 plus B7 unearned,
0.00
0.00
B5 plus B7 earned)
$
$
0.00
13. Total countable income (A4 plus A12)
$
9. Any income exclusion
$ 20
14. SSI/SSP payment level
$
10. Net unearned income (B8 minus B9)
$
15. IHSS share of cost (A13 minus A14)
$
11. Unused $20 exclusion (If B9 is greater than
B8 unearned, enter the difference)
$
12. Earned income exclusion
$ 65
** If there is also a blind or disabled child in the family, the share of cost
65.00
13. Total exclusions (B11 plus B12)
$
shown in Line C is not paid. Enter this amount on Form SOC 294C,
Line A9. The share of cost will be the amount detemined in SOC
14. Remaining earned income (B8 minus B13)
$
294C, Line B16.
15. Net earned income (B14 x 1/2)
$
16. Other earned income deductions
$
17. Total net earned income (B15 minus B16)
$
0.00
18. Total countable income (B10 plus B17)
$
19. SSI/SSP couple payment level
$
20. IHSS share of cost (B18 minus B19)
$
C. SHARE OF COST (higher of A15 or B20) **
$
____________________________________
____________________
WORKER
DATE
SOC 294A (3/02)