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Form Mc 338 - 250 Percent Income Test Work Sheet For The 250 Percent Working Disabled Program-Adults Page 2

II. Allocation to Minor Child(ren) from the Ineligible Spouse. DO NOT allocate from applicant(s). DO NOT include

children on SSI/SSP or children eligible for the 250 Percent Program.

(a)

(b)

(c)

Child One

Child Two

Child Three

(Use additional sheet if more than three children.)

1. Name.

2. Standard SSI allocation.

3. Enter ineligible minor child’s gross

income.

Evaluate for student

deduction. Allow student a $400

monthly disregard from earned

income, up to $1,620 per year.

4. Subtract line 3 from line 2 to

determine the allocation to each

child. Enter zero if a minus.

5. Add columns 4(a), 4(b), and 4(c) to get allocation to ineligible children. Enter here and in Section III, line 4. $ _________________

III. Ineligible Spouse Income Exemption Determination. This section used for evaluation purposes only.

1. Enter gross unearned amount for ineligible spouse from Section I,

line 5(b).

2. Enter amount of gross earned income of ineligible spouse.

3. Add lines 1 and 2.

4. Allocation to ineligible children entered from Section II, line 5.

5. Subtract line 4 from line 3 to get remainder.

6. If line 5 is less than the current standard SSI allocation, STOP.

Please check (4) one

There is no spousal deeming. Do not complete any more boxes

rSpousal deeming

in Section I, column (b). If there is spousal deeming, complete

rNo spousal deeming

Section I, column (b).

IV. 25O Percent Income Eligibility Determination

1. Enter amount from Section I, line 20, rounded to nearest dollar.

2. List 250 percent of the current federal poverty level (FPL).

NOTE: If there is spousal deeming or a couple is applying, use

the FPL for two. If only the income of the applicant is used, use

the FPL for one.

3. If line 1 is less than line 2, the applicant(s) (individual or couple)

are eligible. If a couple is ineligible, redo form with only one

applicant and an ineligible spouse.

MC 338 (05/07)

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Form Mc 338 - 250 Percent Income Test Work Sheet For The 250 Percent Working Disabled Program-Adults Page 2

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