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Form Mc 338 A - Ssi/ssp Income Test Work Sheet For The 250 Percent Working Disabled Program-Adults

State of California—Health and Human Services Agency

Department of Health Care Services

SSI/SSP INCOME TEST WORK SHEET FOR

THE 250 PERCENT WORKING DISABLED PROGRAM—ADULTS

Case name

Case number

Applicant(s) name(s)

Complete the MC 338 250 Percent Income Test Work Sheet before completing this form. Determine whether spousal deeming

applies by reviewing Part III, line 6, of the MC 338. Note: Earnings of the applicant are exempt.

Complete Part I or Part II as appropriate.

Part I. Spousal Deeming Applies

1. Enter the amount from line 10, MC 338 to determine total countable

unearned income.

2. Enter the amount from line 13, MC 338, to determine ineligible spouse’s

earned income after allocation to ineligible children.

3. Enter the amount from line 17, MC 338.

4. Subtract line 3 from line 2. If a minus, enter zero.

5. Divide line 4 by 2 to get ineligible spouse’s net earned income.

6. Add line 1 and line 5 to get total countable income. Enter in Part III,

line 8. Enter the SSI/SSP payment level for two in Part III, line 9.

Part II. Spousal Deeming Does Not Apply

7. Enter amount from line 10, MC 338, to get applicant(s) unearned income.

Also, enter this amount in Part III, line 8.

Part III. SSI/SSP Income Test

8. This is the total income entered pursuant to Part I, line 6, or Part II, line 7.

9. Enter the SSI/SSP payment level for:

one, if only a single applicant is applying or if an individual with an

ineligible spouse is applying and spousal deeming does not apply,

two, if a couple is applying or if an individual with an ineligible spouse is

applying and spousal deeming applies.

10. If line 8 is less than line 9, the applicant(s) are SSI income eligible.

Otherwise, the applicant(s) are ineligible. If a couple is ineligible, redo

with only one applicant.

Eligibility Worker signature

Worker number

Computation Date

County Use

MC 338 A (05/07)

Form Mc 338 A - Ssi/ssp Income Test Work Sheet For The 250 Percent Working Disabled Program-Adults