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III. SHARE-OF-COST DETERMINATION

INSTRUCTIONS

Do not consider community income; use “name on the check” rule. Consider only the parent’s income and income of the

separate child who wants Medi-Cal.

Child/Spousal Support

Payments Received:

Child support is income to the child, not to the parent or caretaker relative.

For AFDC-MN/MI only:

Divide the $50 per month deduction by the number of persons for whom the income is

intended. Any unused remainder will be prorated among the remaining persons who still

have support payments to apply against the deduction.

For ABD-MN only:

Each ABD-MN child for whom absent parent support payments are intended will receive a

one-third deduction from this income.

** Unearned In-Kind Income:

Prorate the unearned in-kind income among the persons who receive the income.

Example: MFBU of four gets free housing. Use in-kind income for four and each person

gets one-fourth of the in-kind income. If pregnant minor in MFBU, add unborn’s share to

the pregnant minor’s share of in-kind income.

*** ABD-MN Deductions:

Allow the ABD-MN child: $20 any income deduction and $65 plus one-half earned

income deduction.

Allow each ABD-MN adult or parent of an ABD-MN child: $20 any income deduction

and $65 plus one-half earned income deduction.

NOTE: If any of the following deductions apply, complete MC 176 W, Part VI before completing Sections A or B.

Educational Expenses................................................. Section 50547

Student Deduction....................................................... Section 50551

$30 Plus 1/3 ................................................................ Section 50551.1

Work Expenses for the Blind ....................................... Section 50551.4

Income for Self-Support .............................................. Section 50551.5

ENTER NAME OF EACH MFBU MEMBER

PERSON TYPE

Parent

Child

NONEXEMPT UNEARNED INCOME:

AFDC-MN/MI and/or ABD-MN

1. RSDI

2. Net income from property

3. Net child/spousal support received*

4. In-kind income**

7. Total (add 1 through 6)

8. ABD-MN $20 any income deduction

(skip if AFDC-MN/MI)

9. Countable unearned income

(7 minus 8; enter in section D, line 15)

NONEXEMPT EARNED INCOME—

ABD-MN ONLY***

10. Gross earned income

11. $65 earned income deduction PLUS

$____________ unused $20 (line 8)

12. Remainder (10 minus 11)

13. Countable earned income (divide line 12 by 2)

(enter in section D, line 16)

NONEXEMPT EARNED INCOME—

AFDC-MN/MI ONLY

14. Net earned income (MC 176 W, Part IV,

line 10) (enter in section D, line 16)

ENTER COMPUTATION FOR CHILD/SPOUSAL SUPPORT and/or UNEARNED IN-KIND INCOME:

Page 3 of 4

MC 176 W.1 (05/07)

Form Mc 176 W.1 - Stepparent Computation When Only The Separate Children Of One Spouse Want Medi-Cal Page 3

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