Form Dhcs 7029 - California Disregard Computation Worksheet - Health And Human Services Agency

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State of California—Health and Human Services Agency
D epartment of Health Care Services
DISREGARD COMPUTATION WORKSHEET
Date: ________________________________________
(PICKLE ELIGIBLE INDIVIDUAL OR COUPLE AND/OR
Case name: ___________________________________
INELIGIBLE SPOUSE WITH
RSDI* INCOME)
Case number: _________________________________
EW number: ___________________________________
A.
POTENTIAL PICKLE PERSON’S NAME
(This person/spouse passed screening.)
1.
Current RSDI Benefit Amount
$ ___________
2.
Was eligible for and received last
SSI/SSP check on ______________
X
___________
DISREGARD
(Date)
(Multiplier)
(Round to
AMOUNT
3.
Total Amount
$ ___________
Nearest $)
$ ___________
B.
POTENTIAL PICKLE PERSON’S NAME
(This spouse also passed screening.)
(Use if BOTH spouses passed the Screening Test.)
1.
Current RSDI Benefit Amount
$ ___________
2.
Was eligible for and received last
SSI/SSP check on ______________
X
___________
DISREGARD
(Date)
(Multiplier)
(Round to
AMOUNT
3.
Total Amount
$ ___________
Nearest $)
$ ___________
C.
INELIGIBLE SPOUSE OF POTENTIAL PICKLE PERSON
(This spouse did not pass screening.)
(Use if one spouse has passed the Screening Test
and one has not, but both have RSDI income.)
1.
Current RSDI Benefit Amount
$ ___________
2.
Date potential Pickle person’s
SSI/SSP was discontinued
OR
Date when ineligible spouse started
receiving RSDI (WHICHEVER IS LATER)
_____________________________
X
___________
DISREGARD
(Date)
(Multiplier)
(Round to
AMOUNT
3.
Total Amount
$ ___________
Nearest $)
$ ___________
*RSDI: Retirement, Survivors, and Disability Insurance under Social Security
DHCS 7029 (06/07)

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