Form Mc 273 - Work Activity Report Page 2
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26. Special Work Expenses—Specify below any special expenses related to your condition which are necessary for you
to work. These are things which you paid for and not things that will be paid for by anyone else.
Specify the amount of the expenses. Attach verification of who prescribed the item or service needed and the cost paid.
(We are required to verify the need for the item or service with the person who prescribed it.)
Example:
Attendant care services, transportation costs, medical devices, work-related equipment, prosthesis,
modifications to your home, routine drugs and medical services necessary to control a disabling condition, diagnostic
procedures, assistants (e.g., if visually impaired, the cost to hire a reader; if hearing impaired, the cost to hire a sign
language interpreter), or similar items or services.
7. Subsidies—Some employers will support disabled individuals with subsidies.
For example, the employer may
subsidize the disabled employee’s earnings by paying more in wages than the reasonable value of the actual work that
was done. (For example, many sheltered work centers subsidize an individual’s earnings.)
❒ Yes
❒ No
Does your employer provide you with subsidies?
If yes, please (a) tell us how much the subsidy is worth and (b) explain the type of subsidy that was given.
a.
$__________________
b.
Explanation of subsidy: ______________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
8. Use this additional space to answer any previous questions or to give additional information that you think will be
helpful.
9. Please read the following statement. Sign and date the form. Provide address and telephone number.
If my employer should need to be contacted, this also authorizes my employer to disclose any information
necessary for the county to evaluate my work activity for my Medi-Cal application based on disability.
I have completed this form correctly and truthfully to the best of my knowledge and abilities.
Signature of applicant or representative
Date
Area code and telephone number
(
)
Mailing address (number, street, apartment number, P.O. box number, or Rural Route)
City
County
State
ZIP code
CHECKLIST FOR COUNTY USE ONLY
1.
Enter amount of client’s gross wages.
$_______________
Does the client have any of the following deductions?
❒
❒
a. Subsidy (see MEPM, Article 22, 22C-2.7)
Yes
No
If yes, enter amount:
$_______________
❒
❒
b. Impairment-related work expenses (IRWEs)
Yes
No
If yes, enter amount:
$_______________
❒
❒
2.
Add a and b above and subtract total from number 1. Is the remainder over the current SGA amount?
Yes
No
If yes, client is engaging in SGA. If any explanations are needed, please use the following space:
Eligibility Worker signature
Worker number
Date completed
Page 2 of 2
MC 273 (05/07)
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