Form Mc 176 P-V - Vehicle Determination Work Sheet For 1931 Group
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1State of California—Health and Human Services Agency
Department of Health Care Services
VEHICLE DETERMINATION WORK SHEET
FOR 1931 GROUP
Case name
Case number
DIRECTIONS
VEHICLE NUMBER ONE
VEHICLE NUMBER TWO
VEHICLE NUMBER THREE
List all vehicles owned by anyone in the MFBU.
Make ___________________
Make ____________________
Make_____________________
NOTE: Complete additional work sheets if more
Model __________________
Model ___________________
Model ____________________
than three vehicles.
Year ____________________
Year_____________________
Year _____________________
STEP ONE—Only Unlicensed Vehicles on Indian Reservation Which Do Not Require Licensing and All Licensed Vehicles. For All
Other Vehicles, Go to Step Two.
A vehicle used by or for the benefit of any person living in the home for any reason listed below is exempt.
1. On the job or for income producing purposes even if only on a seasonal basis or temporarily unemployed.
2. Long distance travel essential to individual’s employment, e.g., traveling sales, migrant farm worker moving from job to job.
3. Home (only one vehicle per household).
4. Transportation of incapacitated or disabled individual living in the home.
5. Transportation of primary fuel/water for the home.
Is vehicle exempt?
Yes
No
Yes
No
Yes
No
If yes, list reason and STOP.
If NO, go to Step Two.
Reason: _________________
Reason: _________________
Reason: __________________
STEP TWO—Only Vehicles Not Exempt in Step One
$
$
$
A. Enter estimate of Fair Market Value (FMV).
FMV
________________
FMV
_________________
FMV
_________________
–
4,650
–
4,650
–
4,650
B. Licensed Only—If Unlicensed, Go to Step Two (C).
___________
_________
____________
Enter excess FMV (estimate of FMV minus $4,650).
If zero, then exempt, STOP.
$
$
$
If not zero, go to Step Two (C).
Excess FMV
___________
Excess FMV
__________
Excess FMV
____________
C. All Remaining Vehicles—Enter encumbrance
(amount owed).
$ _________
$ ________
$ _________
Amount owed
Amount owed
Amount owed
D. Determine equity value (EV) of vehicle (FMV of vehicle
Exempt:
Yes
No
Exempt:
Yes
No Exempt:
Yes
No
from Step Two (A) minus encumbrance in
Step Two (C)). If $1,500 or less, then exempt. STOP.
$ _________
$ ________
$ _________
EV
EV
EV
STEP THREE—Countable Vehicle Value
A. Compare Step Two (B) and amounts listed for
Check One
Check One
Check One
nonexempt vehicles in Step Two (D).
Excess FMV
Excess FMV
Excess FMV
Enter the lesser value.
$ _______________
$ _______________
$ ________________
or
or
or
EV
EV
EV
$ _______________
$ _______________
$ ________________
B. Enter $1,500 in the column under the one vehicle with
the highest equity value. If excess FMV is the lesser
amount, enter zero. Enter zero in all columns where
$1,500 is not entered.
– $ _______________
– $ _______________
– $ ________________
C. Subtract Step Three (B) from Step Three (A) and enter
result. If zero, then car is exempt. If not zero, then
enter amount on Property Reserve Work Sheet
(MC 176 P (Back) 1931).
– $ _______________
– $ _______________
– $ ________________
MC 176 P-V (05/07) 1931 Group
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