Form Mc 210 S-E - Student Educational Expenses
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1State of California—Health and Human Services Agency
Department of Health Care Services
Medi-Cal Program
STUDENT EDUCATIONAL EXPENSES
COUNTY USE ONLY
(Supplement to the Medi-Cal Statement of Facts—MC 210)
Case Name: ___________________
______________________________
Case No.: _____________________
Worker No.:____________________
Date: _________________________
See MEM 50447 for allowable
If you or any family member are in college or attending a similar educational institution, please fill in the following:
education expenses.
A. Student’s name(s):
EXEMPT:
Name of institution(s):
Full-time
Part-time
Full-time
Part-time
Entire amount
Status of student(s):
Grad
Undergrad
Grad
Undergrad
Only expenses
B. Grants, Loans, Scholarships, Fellowships:
VERIFICATION (List):
Amount received:
$
$
Source(s) of grants, loans, etc.:
How often received (monthly, quarterly, etc.)?
C. Expenses Per Term:
Is term a semester, quarter, year?
$
Tuition/fees:
$
$
Books, equipment, and school supplies:
$
$
Child care necessary for school attendance:
$
Transportation costs allowed
(show computations):
D. Transportation to School/Child Care:
Round trip miles per day:
School attended how many days per week:
Type of transportation used (own car, borrowed car, car
pool, bus, etc.):
Costs (per month):
Amount paid by student (if not own car)
$
$
�
�
Amount paid by riders
$
$
Parking, tolls, etc.
$
$
�
Is public transportation (bus, train, etc.) available?
Yes
No
Yes
No
If yes, indicate cost:
$
$
�
MC 210 S-E (05/07)
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