Form Mc 280 Tb - Tuberculosis (Tb) Program Financial Eligibility Work Sheet-Eligible Child With Ineligible Parent Or Parent(S)
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1
2Department of Health Care Services
State of California—Health and Human Services Agency
TUBERCULOSIS (TB) PROGRAM
FINANCIAL ELIGIBILITY WORK SHEET—ELIGIBLE CHILD
WITH INELIGIBLE PARENT OR PARENT(S)
CASE NAME
CASE NUMBER
APPLICANT’S NAME
PART I. INELIGIBLE PARENT’S UNEARNED INCOME
1. Parent’s unearned income—do not include public assistance (PA), other PA, or TB parent’s income.
Do not include parent’s income if spouse is PA, other PA, or TB:
$ ____________
2. Allocation for ineligible children (if no children, enter zero in Part I.2.c.). Do not include TB applicant or
TB-eligible children.
#1
#2
#3
#4
CHILD
CHILD
CHILD
CHILD
Name
Name
Name
Name
a. Standard SSI allocation (Federal
Benefit Rate [FBR] for a couple minus
FBR for an individual):
b. Minus child’s income:
–
–
–
–
c. Total allocation:
________
+ _______
+ _______
+ _______ = $ ____________
3. Remaining unearned income (subtract line I.2.c. from line I.1.):
$ ____________
PART II. INELIGIBLE PARENT’S EARNED INCOME
1. Parent’s gross earned income: ............................................................................................................. $ ____________
2. Unused portion of allocation for ineligible child(ren): ............................................................................ $ ____________
3. Remaining earned income (subtract II.2. from II.1.):............................................................................. $ ____________
IF THERE IS NO INCOME REMAINING AND I.3 AND II.3. ARE BOTH ZERO, DO NOT DEEM, GO TO PART IV.
IF THERE IS INCOME, PROCEED WITH PART III.
PART III. COMBINED INCOMES—Ineligible Parents
PART IV. TB ELIGIBILITY CALCULATION
Unearned Income
1. Deemed income from Part III.15.
1. Remaining unearned income (after allocation) or zero (from I.3.)
2. Eligible child’s own OASDI income
2. A. Subtract general income exclusion
–20
3. Other unearned income
B. Subtract other unearned income deductions
–
4. A. Subtract general income exclusion
–20
3. Countable unearned income (to III.11.)
B. Subtract other unearned income deductions
–
Earned Income
5. Countable unearned income (IV.1. + IV.2. + IV.3. – $20)
4. Remaining earned income (from II.3.)
6. A. Child’s countable earned income
(subtract $65 +
/
remainder)
–
1
2
5. Subtract balance of general income exclusion
6. Remainder
B. Subtract other earned income deductions
–
7. A. Subtract work expense exclusion
–65
7. Total countable income
B. Subtract other earned income deductions
–
8. Current TB income standard
8. Remainder
–
If line IV-7 is less than or equal to line IV.8., this person is income eligible.
9. Subtract
1
/
remainder
2
10. Countable earned income (to III.12.)
Deemed Income
11. Countable unearned income (from III.3.)
12. Add countable earned income (from III.10.)
13. Total countable income (from III.11. + III.12.)
14. Subtract parent deduction*
–
15. Deemed income. Enter on Line IV.1.
* Individual FBR if one ineligible parent lives with child; couple FBR if both ineligible parents live with child.
MC 280 TB (05/07)
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