Form Mc 282 Tb - Tuberculosis (Tb) Program Income Eligibility Work Sheet

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Department of Health Care Services
State of California—Health and Human Services Agency
TUBERCULOSIS (TB) PROGRAM
INCOME ELIGIBILITY WORK SHEET
Use this form for an individual or applicant with spouse where both may be eligible for the TB Program.
NOTE: Married—If the applicant is married and living with his/her spouse, use only the income received in the applicant’s own name. For
property, only use the applicant’s separate property and one-half of community property.
Case name
Case number
Applicant’s name
TB INDIVIDUAL’S TOTAL COUNTABLE INCOME
a. TB APPLICANT
b. TB SPOUSE
PART A.
UNEARNED INCOME
1. Gross Unearned Income:
2. Subtract Any Income Deduction:
–20
3. Subtract Other Unearned Income Deductions:
4. Total Countable Unearned Income:
PART B.
EARNED INCOME
5. Earned Income:
6. Subtract Balance of General Exclusion:
[If Not Offset by Unearned Income (Line 2)]
7. Remaining Earned Income (5 minus 6):
8. Subtract Work Expense Exclusion:
–65
9. Subtract Other Earned Income Deductions:
10. Remaining Earned Income:
1 /
11. Subtract One-Half (
) Remaining Earned Income:
2
12. Total Countable Earned Income:
13. Total Countable Income (add lines 4 and 12):
PART C.
TB ELIGIBILITY CALCULATION
14. Current TB Income Standard for Individual:
15. Enter Total Countable Income (line 13):
(If line C.15 is less than or equal to line C.14, the Applicant is TB income eligible.)
Eligibility Worker signature
Worker number
Computation date
County Use Only
®
MC 282 TB (05/07)

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