Form Mc 272 - Sga Work Sheet
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1Department of Health Care Services
State of California—Health and Human Services Agency
Name of disabled person
Social security number
SGA WORK SHEET
(Used when gross earned* income is over the current SGA amount.)
1. Earned Income
a. Gross average monthly earnings
$ ____________
b. Payment in kind (e.g., room and board) which is not a
condition of employment (use current market value)
____________
c. Other
____________
d. TOTAL GROSS EARNINGS (add a, b, and c)
$ ____________
2. Impairment-Related Work Expenses (IRWEs)
(see MEPM, Article 22, 22C-2)
a. Attendant care services
$ ____________
b. Transportation costs
____________
c. Medical devices
____________
d. Work-related equipment
____________
e. Prosthesis
____________
f.
Residential modifications
____________
g. Routine drugs and routine medical services
____________
h. Diagnostic procedures
____________
i.
Nonmedical applications and devices
____________
j.
Assistants (e.g., if visually impaired, cost to hire reader)
____________
k. Other items and services
____________
3. TOTAL IRWEs: Add (total of 2a through 2k)
$ ____________
4. TOTAL SUBSIDY (e.g., some employers employ disabled persons and subsidize their
wages by paying them the same wages as a nondisabled employee though they may
be performing less strenuous work, or working less hours) (from MC 273, number 7) $ ____________
5. NET COUNTABLE EARNINGS (subtract 3 and 4 from 1d)
$ ____________
Ì
Ì
Are current countable earnings greater than $ ________________________?
Yes
No
G
(Insert current SGA amount)
If the answer is No, send a disability referral to SP-DAPD. In Item 10 of the MC 221, Disability
G
Determination and Transmittal, write in “No SGA issue.” Attach copy of MC 272 to the MC 221.
If the answer is Yes, the client is engaging in SGA. Deny the disability claim. (Evaluate client for the
G
Working Disabled Program.)
*NOTE: Income information obtained from completed MC 273 (Work Activity Report).
Eligibility Worker signature
Worker number
Date completed
MC 272 (05/07)
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