Form Mc 337 - 100 Hours Or More Unemployed Parent Determination Worksheet

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State of California—Health and Human Services Agency
Department of Health Care Services
100 HOURS OR MORE UNEMPLOYED PARENT DETERMINATION WORKSHEET
Either Section 1931(b) or Medically Needy(MN) Deductions but not Both
Case name
Case number
Effective date
Year:
Month:
III.
DETERMINING NET NONEXEMPT EARNED
I.
NONEXEMPT EARNED INCOME OF ABD PERSON
INCOME
IN MFBU AND INCOME OF THEIR
SPOUSE/PARENT (except PA/Other PA )
1
Countable Earned Income (Enter
MN Deductions Only
the amount from either I.6 for ABD
MN deductions or II.5 for AFDC MN
(The age of a parent is not a factor in establishing
or 1931(b) deductions)
$
deprivation for a child.)
1
Earnings of Principal Wage Earner
2
Court Ordered Child/Spousal
(PWE)
$
Support Deduction
$
2
Earnings of Second Parent/Spouse
$
3
Dependent Care Deduction
$
3
Gross Earned Income (add lines I.1
plus I.2)
$
4
Allocation to PA Member
$
4
$65 Earned Income Deduction plus
$20 Any Income Deduction
$
85
5
Allocation to Excluded Children
$
6
Health Insurance Premiums
5
Remainder (line I.3 minus I.4)
$
(MN deduction only)
7
Other Applicable Deductions—Either
6
Column I. Countable Earned Income
MN or Section 1931(b) but not both
(1/2 of line I.5)
$
(itemize in County Use Section)
$
II.
NONEXEMPT EARNED INCOME OF 1931(b)
8
Total Deductions (add lines III.2
PERSONS IN AN MFBU or MN with NO ABD
through III.7)
$
PERSON
9
Total Net Nonexempt Earned
1
Earnings of Principal Wage Earner
Income (line III.1 minus III.8
(PWE)
$________ – $90 =
$
rounded down to the nearest dollar) $
2
Earnings of second Parent/Spouse
10
100% FPL Limit for Family Size
$ ________ – $90 =
$
of _____
3
Total ( add lines II.1 plus II.2)
$
(Number in MFBU including
children; do not include persons
4
1931(b) Self-employed 40%
who are PA or excluded)
$
Deduction (if applicable) **
$
5
Column II. Countable Earned
11
Is Total Net Nonexempt Earned
Yes
Income (line II.3 minus II.4)
$
Income at or below 100% of the FPL?
No
• If line III.11 is NO, then the PWE is employed and there is
**NOTE: Section 1931(b) self-employed persons are allowed
a choice of actual allowable business expenses or 40% from
no Unemployed Parent deprivation
the MFBU's total self-employment income. This may be more
• If line III.11 is YES, then the PWE is considered an
beneficial than using MN deductions even if the person is an
Unemployed Parent.
ABD.
• Evaluate family for 1931(b) if the youngest child in the
home is under 18 or 18 and enrolled full-time in school
and expected to graduate prior to age 19. If not and the
youngest child is under 21, evaluate family for MN.
• Section 1931(b) recipients may work 100 hours or more
without this income test if there is no break in aid or
change in deprivation.
County Use
Eligibility Worker name
Worker/Caseload number
Date
MC 337 (05/07)

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