Form Qr 285b - Calfresh Budget Worksheet/quarterly Reporting Households
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALFRESH BUDGET WORKSHEET/QUARTERLY REPORTING HOUSEHOLDS
CASE NAME
COMPANION CASE REFERENCE
CASE NUMBER
CLASSIFICATION
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NA
PA
MIXED
TC
CERTIFICATION
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FROM
THROUGH
BUDGET IS BASED ON:
OTHER
MID-QUARTER REPORT
PERIOD
QR 7
PART 1 - GROSS INCOME
OTHER
A. NONEXEMPT GROSS UNEARNED INCOME
SOCIAL SECURITY,
CHILD/SPOUSAL
SCHOLARSHIPS,
UIB, DIB, PENSIONS
SUPPORT
GRANTS, LOANS
$
$
$
$
1. Month 1/Year ________/________
$
$
$
$
2. Month 2/Year ________/________
$
$
$
3. Month 3/Year ________/________
$
Total $________ (A4)
4. Unearned Income (A1 + A2 + A3)
Total $ _______ (A5)
5. QR Averaged Gross Unearned Income (A4 ÷ number of months)
Total $ _______ (A6)
6. Cash Aid
Total $ _______ (A7)
7. Less Child Support Paid (enter any remainder in B6)
8. Total Gross Unearned Income (A5 + A6 - A7)
Total $ _______ (A8)
B. NONEXEMPT GROSS EARNED INCOME
TRAINING
GROSS SALARY/WAGES
SELF EMPLOYMENT
ALLOWANCES
$
$
$
1. Month 1/Year ________/________
$
$
$
2. Month 2/Year ________/________
$
$
$
3. Month 3/Year ________/________
4. Total Gross Earned Income (B1 + B2+ B3)
Total $________ (B4)
5. QR Averaged Gross Earned Income(B4 ÷ number of months)
Total $ _______ (B5)
6. Less Remainder of Child Support Paid (if not fully used in Section A)
Total $________ (B6)
7. Total Gross Earned Income (B5 - B6)
Total $ _______ (B7)
PART 2 - GROSS INCOME
C. GROSS INCOME TEST
1. Maximum Gross Income allowed for Household
$
Size of ______ (from table)
$
2. Total Gross Income (A8 + B7) =
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Total $ _______ (C3)
YES
NO
NA
3. Gross Income Eligible? (Is C2 less than or equal to C1?)
PART 3 - NET INCOME
DOCUMENTATION
D. NONEXEMPT GROSS INCOME
$
1. Gross Earned Income (B5)
INCOME:
$
2. Adjusted Gross Earned Income (80% of D1)
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3. Less Remainder of Child Support Paid (B6)
Weekly $ _________ x 4.33 = $ __________
$
(if not fully used in Section A)
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Biweekly $ ________ x 2.167 = $ __________
4. Total Gross Earned Income (D2 - D3)
$
(If negative amount, enter zero)
HOUSEHOLD WITH ELDERLY/DISABLED
$
5. Total Gross Unearned Income (A8)
MEMBER:
6. Nonexempt Gross Income (D4 + D5)
$
Is there an elderly member who is disabled and who
E. STANDARD
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cannot purchase and prepare meals?
YES
NO
Standard Deduction
$
F. DEPENDENT CARE (100% OF COSTS)
$_______________
If Yes, is the household’s income (less the elderly
disabled member’s and spouse’s income) less than
G. HOMELESS SHELTER DEDUCTION
$_______________
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165% of FPL?
YES
NO
H. TOTAL DEDUCTIONS (E + F + G)
$_______________
If Yes, certify the elderly and disabled member (and
spouse) as a separate household.
I. ADJUSTED NET INCOME
1. Nonexempt Gross Income (D6)
$_______________
CHILD SUPPORT (COURT ORDERED)
2. Total Deductions (Line H)
$_______________
PAID OUT
3. Adjusted Net Income (I1 - I2)
$_______________
Total $___________
Total ÷ by number of months $___________
J. SHELTER DEDUCTION
1. Total Housing Costs
$_______________
Amount used in A7: $ __________
2. Total Utility Allowance
$_______________
Remainder to be used in B6: $____________
3. Total Shelter costs
$_______________
4. Allowable Shelter costs (50% of I3)
$_______________
QTR AVG
MID QTR AVG
5. Excess Shelter costs (J3 - J4)
$_______________
6. Maximum Allowance For Shelter
$_______________
7. Allowable Shelter Deduction (Lesser of J5 or J6)
$ ______________
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Dependent Care
K NET MONTHLY INCOME (I3 - J7)
$_______________
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L. NET INCOME TEST
Utilities
1. Household Size
_______________
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SUA
LUA
TUA
2. Maximum Net Income Allowable (from table)
$_______________
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Housing
PRORATED
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3. Net Income eligible
YES
NO
ALLOTMENT
SUPPLEMENT
E.W. Initials/Date
QR 285B (8/11) RECOMMENDED FORM
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