Form Mc 326 A - Supplemental Security Income (Ssi) Methodology Adult Income Eligibility Work Sheet

State of California—Health and Human Services Agency

Department of Health Care Services

SUPPLEMENTAL SECURITY INCOME (SSI) METHODOLOGY ADULT

INCOME ELIGIBILITY WORK SHEET

(Individual or couple, applicant with an ineligible spouse)

Case name

Case number

Applicant’s name

PART I.

INELIGIBLE SPOUSE’S UNEARNED INCOME

1. Ineligible spouse’s total unearned income—do not include if ineligible spouse is receiving

public assistance (PA) income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

2. Allocation for ineligible children (if no children, enter zero in Part 1.2.c.).

Do not include PA or eligible children or children applying for this program.

CHILD NUMBER 1 CHILD NUMBER 2

CHILD NUMBER 3 CHILD NUMBER 4

Name

Name

Name

Name

a. Standard SSI allocation (couple Federal

Benefit Rate [FBR] minus individual FBR)

b. Subtract child’s income (

)

evaluate for student deduction

—

—

—

—

c. Total allocation

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ +____________+ ____________+ __________ =$

3. Remaining unearned income (subtract line I.2.c. from I.1.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

PART II. INELIGIBLE SPOUSE’S EARNED INCOME

1. Ineligible spouse’s gross earned income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

2. Unused portion of allocation for ineligible child(ren) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

3. Remaining earned income (subtract II.2. from II.1.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

PART III. INELIGIBLE SPOUSE’S TOTAL INCOME AFTER ALLOCATIONS (Add I.3. and II.3.)

If less than the standard SSI allocation (the difference between the FBR for a couple and the FBR

for an individual) deeming not applicable. Make no entry for ineligible spouse’s income in Part IV. . . . . . . . . . . . . . . . . . . . . . $

PART IV. COMBINED INCOMES (Eligible individual or couple and/or ineligible spouse after ineligible child allocations)

Unearned Income

1. Applicant’s gross unearned income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

2. Ineligible spouse’s unearned income (line I.3.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

+

3. Combined unearned income (add lines IV.1. and IV.2.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

20

4. Subtract general income exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ____________________

—

5. Combined countable unearned income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

Total Unearned

Earned Income

6. Earned income of applicant and spouse (use amount from line II.3. for ineligible spouse) . . . . . . . . $

7. Subtract balance of general exclusion not offset by unearned income (line IV.4.). . . . . . . . . . . . . . . $

8. Remaining earned income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

65

9. Subtract work expense exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

—

10. Remaining earned income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

—

11. Subtract 1/2 remaining earned income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

12. Subtract the disabled/blind individual’s impairment-related work expenses/blind work expenses,

—

if any . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

13. Countable earned income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

Total Earned

14. Total countable income (add lines IV.5. and IV.13.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________________

Combined Total

PART V. SSI ELIGIBILITY CALCULATION

1. Current SSI/SSP income standard for an individual or a couple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. Enter total countable income (line IV.14.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

If line V.2 is less than or equal to V.1., the applicant is SSI income eligible.

County use only

Eligibility Worker signature

Worker number

Computation date

MC 326 A (05/07)