Form Mc 010 - Qualified Disabled Working Individual Information Notice Page 2
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1
2C.
Fill in the MONTHLY amounts for the person in A and, if married, the spouse in B.
13.
Gross earnings for the person who wants
to be a QDWI
$ ____________
14.
Gross earnings for the spouse
$ ____________
15.
Total – Add lines 13 and 14
$ ____________
– $ 65
16.
Subtract $65
____________
17.
Remainder
$ ____________
18.
Divide line 17 by 2
$ ____________
19.
Total – Add lines 6, 12, and 18.
$ _____________
_____________
If you are not married, this amount cannot exceed $1,265 per month. If you are married and living with your spouse, this total
cannot exceed $1,692 per month. However, if you have children or your spouse has low income, this total may be higher.
REQUIREMENT 3
A QDWI who is not married or not living with his/her spouse must have countable property which is equal to or less than
$4,000. A QDWI who is married and living with his/her spouse must have countable property which is equal to or less than
$6,000.
The following gives examples of properties which count. PLEASE NOTE: The home you and/or a spouse live in does not
count. One car used for transportation does not count. If you apply at the county department of social services as a QDWI,
the county may treat the property listed on this form differently. There are other types of property which will also be looked at
by the county department of social services. This other property may or may not count toward the QDWI property limit.
Fill in the value of the following property which belongs to you, your spouse, or both of you.
1.
Checking accounts
$ ____________
2.
Savings accounts
$ ____________
3.
Certificates of Deposit
$ ____________
4.
Stocks
$ ____________
5.
Bonds
$ ____________
6.
A second car (value minus amount owed)
$ ____________
7.
A second home (value minus amount owed) $ ____________
8.
The cash surrender value of life insurance
policies if the face value of all policies
combined exceeds $1,500.
$ ____________
(Do not include “term” insurance policies.)
9.
Total – Add lines 1 through 8.
$ ____________
____________
This amount cannot exceed $4,000 for a single person or $6,000 for a couple.
REQUIREMENT 4
A QDWI must meet certain other Medi-Cal conditions. For example, you must be a California resident.
Additional Information
For more information or if you wish to apply as a QDWI, please call the number of your local county department of social
services.
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MC 010 (05/07)
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