Form Qr 29 - Applicant Test
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICANT TEST
CASE NAME
CASE NUMBER
CW NAME
DATE
Determine whose needs to consider in the MBSAC size and select the corresponding MBSAC amount.
Use a best estimate of countable income from AU members (including penalized AU members), certain non-AU members and
sanctioned/excluded members.
Deduct $90 from the gross earned income of each family member whose earnings are used on the QR 29.
Compare the family’s total countable income to the MBSAC plus special needs to determine financial eligibility.
MONTH AND YEAR ___________
1.
NUMBER OF FAMILY MEMBERS WHOSE NEEDS
SELF-EMPLOYMENT INCOME CALCULATION
ARE CONSIDERED IN MBSAC
PERSON 1
PERSON 2
EARNINGS FROM SELF-
2.
CORRESPONDING MBSAC FOR
Line 5a
Line 5d
EMPLOYMENT
FAMILY SIZE IN #1 ABOVE
$
Gross earnings from self
$
$
employment
3.
RECURRING SPECIAL NEEDS
+
Expenses
-
-
4.
TOTAL GROSS INCOME LIMIT
=
Actual
40%
Net self-employment
5.
GROSS EARNINGS COMPUTATION
income (Include in line 5
$
$
for appropriate person)
a.
Gross Earnings (Person 1)
$
b.
Disregard
-
90
c.
SUBTOTAL
=
d.
Gross Earnings (Person 2)
$
e.
Disregard
-
90
f.
SUBTOTAL
=
g.
Gross Earnings (Person 3)
$
h.
Disregard
-
90
i.
SUBTOTAL
=
j.
TOTAL (Line 5c, 5f and 5i)
$
6.
SOCIAL SECURITY BENEFITS
+
7.
V.A. BENEFITS
+
8.
UIB
+
9.
CHILD/SPOUSAL SUPPORT RECEIVED
(Less CSSD)
+
10. UA CONTRIBUTION (From CW 71)
+
11. UNEARNED IN-KIND (Total received)
+
12. ALL DISABILITY INCOME
+
13. OTHER (Specify)
+
14. TOTAL COUNTABLE INCOME
(Line 5j through Line 13)
=
15. Is total countable income (Line 14) less than the total gross income limit
(Line 4)?
YES; eligible, complete QR 30.
NO; ineligible.
QR 29 (5/04) INTAKE FINANCIAL TEST - RECOMMENDED FORM
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