Form Mc 282 Tb - Tuberculosis (Tb) Program Income Eligibility Work Sheet Page 2
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1
2INSTRUCTIONS
INCOME ELIGIBILITY WORK SHEET MC 281 TB
(Individual or Applicant With an Ineligible Spouse)
PART I.
INELIGIBLE SPOUSE’S UNEARNED INCOME
Do not include ineligible spouse’s income if he/she receives any public assistance (PA).
Line
I.1.
Enter the ineligible spouse’s unearned income.
Line
I.2.
(If there are no children, enter zero on line 2.c.) Enter each ineligible child’s first name in boxes provided on line
2.a., enter the standard SSI allocation for any ineligible child(ren) not on PA or applying for or eligible for the TB
program. On line 2.b., enter any income for each of the children excluding $400 per month, up to $1,620 per year
of student income. On line 2.c. enter the remainder for each child and total the allocation for each child.
Line
I.3.
Subtract line I.2.c from line I.1 (unearned income) and enter the difference. This is the remaining unearned income
amount unless the allocation amount (line I.2.c.) exceeds line I.1 (countable unearned income). In the latter case,
the negative figure on line I.3. is carried over to line II.2. (unused portion of allocation).
PART II.
INELIGIBLE SPOUSE’S EARNED INCOME
Line
II.1.
Enter the ineligible spouse’s gross earned income.
Line
II.2.
Enter the amount of any allocation for ineligible children that is not offset by countable unearned income (line I.2.c.
minus line I.3.). If line I.1. is equal to or greater than line I.2.c, enter zero in line II.2.
Line
II.3.
Subtract the allocation amount on line II.2. from line II.1. (gross earned income) and enter the difference.
PART III. INELIGIBLE SPOUSE’S TOTAL INCOME AFTER ALLOCATIONS
Add the amounts in lines I.3. and II.3. to determine the total income after allocations.
NOTE: If, at this point (after the allocation for ineligible children), the total earned and unearned income amount is less than the standard SSI
allocation (the difference between the Federal Benefits Rate [FBR] for a couple and the FBR for an individual), there is no income available
for deeming to the applicant. In this case, use only the applicant’s income in Part IV and the current TB income standard for an individual in
Part V. If there is combined earned and/or unearned income remaining in excess of the standard SSI allocation, use the amounts from
lines I.3. and II.3. in Part IV and the current TB income standard for a couple in Part V.
PART IV. COMBINED INCOME
Line
IV.1.
Enter the applicant’s or potentially eligible couple’s unearned income.
Line
IV.2.
Enter the ineligible spouse’s unearned income from line I.3. unless there is no deeming according to Part III.
Line
IV.3.
Enter combined unearned income of applicant(s) (line IV.1.) and/or ineligible spouse (line IV.2.).
Line
IV.4.
A. Enter the $20 any income exclusion.
Line
IV.4.
B. Subtract any other unearned income deductions.
Line
IV.5.
Subtract line IV.4. from line IV.3. and enter the difference. (If line IV.3. is less than $20, enter zero in line IV.5.)
Line
IV.6.
Enter combined earned income of the ineligible spouse (unless there is no deeming from the ineligible spouse
according to Part IV.) and the applicant(s). Use line II.3 for ineligible spouse’s income. If there is no deeming,
enter only the applicant’s earned income.
Line
IV.7.
Enter unused portion of the $20 any income exclusion not offset by unearned income.
Line
IV.8.
Subtract line IV.7. from line IV.6. and enter the difference.
Line
IV.9.
A. $65 work expense exclusion.
Line
IV.9.
B. Subtract any other earned income deductions.
Line IV.10.
Subtract line IV.9. from line IV.8. and enter the difference.
Line IV.11.
Enter half of the amount of line IV.10.
Line IV.12.
Subtract line IV.11. from line IV.10. and enter the difference.
Line IV.13.
Add line IV.5. and line IV.12 and enter total. This is the amount of income to be considered in determining TB
eligibility. Enter on line V.2.
PART V. TB ELIGIBILITY CALCULATION
Line
V.1.
Enter the current, applicable TB level. If income is deemed from the ineligible spouse, use the TB income standard
for an individual.
Line
V.2.
Enter total countable income from line IV.13.
If line V.2. (total countable income) is less than or equal to the current TB payment level, the applicant(s) is/are
income eligible for the TB program.
In a situation where there is a potentially eligible child and parent with an ineligible spouse, first determine the
eligible parent’s TB income eligibility using this work sheet. If the parent is eligible, determine the child’s financial
eligibility using only the eligible child’s countable income.
MC 281 TB (05/07)
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