Form Mc 176 Ma - 1931 - Sec. 1931 Recipient Budget Form For Determining Net Non-Exempt Income And Section 1931 Income Eligibility For Recipients Under Alternative A

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CASE NAME
COU
NTY DISTR ICT
COU
NTY USE
EFFECT IVE
ELiG
. DATE FOR TH IS BUDGET:
D
NEWAPP.
D
REDETERMINATION
D
CHANGE
D
RETRO ELiG.
D
CORRECTION
MONTH:
-------
YEAR:
- - - - -
NAME
MFBU
MEMBER #1
NAME
MFBU
MEMBER #6
OTHER
CO
VERAGE
NAME
MFBU
MEMBER #2
NAME
MFBU
MEMBER #7
NAME
MFBU
MEMBER #3
NAME
MFBU
MEMBER #
8
NAME
MFBU
MEMBER #4
NAME
MFBU
MEMBER #9
NAME
MFBU
MEMBER #5
NAME MFBU MEMBER #10
UNEARNED
NCO
ME MFB
U
MEMBER
#
-
-
UNEARNED
INCO
ME
MFBU
MEMBER #
TOTAL
MFBU
-
UNEARNED
NCO
ME
ENTER UNEARNED
NCO
ME OF EACH MFB
U
$
- - - - - - - - - - - - -
:
$
- - - - - - - - - - - - -
1
MEMBER, THEN T OTAL FOR
MFBU (DO
NOT
.
UNEARNED
NCO
ME MFB
U
MEMBER #
UNEARNED
INCO
ME
MFBU
MEMBER #
INCLUDE NON-EXEMPT DISAB IL ITY-BASED
·
-
- - - - - -
.
·
-
:
-
INCO
ME HERE)
$
$
- - - - - - - - - - - - -
:
$
-
- - - - - - - - - - - -
2
o
EXEMPT
INCO
ME (LIST EXEMPT
NCO
ME HERE
)
EDUCAT
IO
NAL EXPENSE (§50547)
-$
- - - - - - -
3
o
$50 SU
PPORT RE CEIVED
(§
50554
5)
-$
- - - - - - -
BOX4
4
REMAINING NON-EXEMPT UNEARNED INCOME
0
$
- - - - - - -
TOTAL
MFBU
OBI
OF
MFBU
MEMBER #
5
ENTER DISAB ILITY-BASED
NCO
ME (OB
I)
OF
DISAB ILITY-BASED
- -
EACH
MFBU
MEMBER, THEN T OTAL FOR
MFBU
INCOME
$
- - - - - - - - - - - -
.
OB
I
OF MFB
U
MEMBER #
- -
·
OB
I
OF
MFBU
MEMBER #
- -
:
$
- - - - - - - - - - - - -
·
OB
I
OF
MFBU
MEMBER #
-
-
$
- - - - - -
$
$
- - - - - - - - - - - - -
- - - - - - - - - - - - -
.
6
$240
DEDUCT
IO
N
-
$240
REMAINING NON-EXEMPT DISABILITY - BASED
BOX7
7A UNUSED
$240
(L NE 6-
7
INCOME
(OB
I) (
F DEDUCT
IO
N
EXCEEDS
L NE 5: IF NEGAT IVE ENTER
0)
$
- - - - - - - - - - -
DISAB ILITY BASED
INCO
ME
,
ENTER
"0")
0$
- - - - - -
(UNUSED $24 0)
ENTER EARN ING
S
FOR UP T
O
TVYO
MFBU
TOTAL
MFBU
MEMBER
S,
THEN T OTAL FOR
MFBU
(IF 3 OR
EARN INGS OF
MFBU
MEMBER #
- - -
EARN ING
S
OF
MFBU
MEMBER #
8
- - -
EARN INGS
MORE PER
SO NS
W ITH EARN
NGS
, SK P
LINES 8
&
9 AND PR OCEED T
O
VYORK SHEET FOR
3+
$
$
EARNER
S)
$
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - -
TOTAL REMAINING NON-EXEMPT UNEARNED INCOME,
9
o
$
UNUSED
$240
DEDUCT
IO
N (FR OM
BOX
7A)
14
NON-EXEMPT DISABILITY-BASED INCOME & NON-
-$
EXEMPT EARNED INCOME (TOTAL FROM BOX 4, 7 & 13)
- - - - - - - - -
REMA N
NG
NON-EXEMPT EARNED INCOME
(O
R
10
FR OM
LI
NE 12WORKSHEET ): IF DED UCT
IO
N
15
o
CH
ILDISPOU
SAL
SU
PPORT PYMTS (§50554
)
EXCEEDS EARNED
INCO
ME, ENTER
"0"
0
$
- - - - -
-$
- - - - - - -
--
11
50% DEDUCT
IO
N (D IVIDE AM
OU
NT NLNE1
0
BY
16
A LLOCAT
IO
N
TO
EXCLUDED CHILDREN (§5
0558)
2
)
0
$
o
-$
12
o
DEPENDENT CARE DEDUCT
IO
N
(§50553 5)
17
o
ALL OCAT
IO
N
TO
PA FAM L Y MEMBER
(§
50557)
-$
'
$
BOX 13
13
T OTAL
MFBU
NET NON-EXCEMPT
INCO
ME
(ROU
NDED
REMAINING NON-EXEMPT EARNED INCOME
18
DOVvN
TO
THE NEAREST DOLLAR
)
$
- - - - -
0$
- - - - - - - - -
19
SEC. 1931
MBSAC INCO
ME LIMIT FOR FAM ILY
$
- - - - - - - - -
o
o
NOT ELI GIBLE IF
NO
SNEEDE- EL IGIBLE CLASS MEMBER, EVALUATE FOR OTHER
IF
INCO
ME FR OM
LI
NE
18 IS
LESS THAN L MIT
ELi
G BLE
MEDI-CAL PR
OG
RAMS: IF SNEEDE - EL IGIBLE CLASS MEMBER, EVALUATE FOR SEC
FR OM LINE 19
,
FAM L Y IS
INCO
ME
ELIGI
BLE
19 31 UNDER SNEEDE
ELiG BIL ITYWORKER
S SI
GNATURE
W ORKER NUMBER
I
CO
MPUTAT
IO
N DATE
I
COU
NTY USE
State of
Cali
fomia
-
Hea lth And Human
Servic
es Agency
Department of Health Care Services
SEC. 1931 RECIPIENT BUDGET FORM FOR DETERMINING NET NON-EXEMPT INCOME
AND SECTION 1931 INCOME ELIGIBILITY FOR RECIPIENTS UNDER ALTERNATIVE A
I
MC
176 MA
-
1931
Group-
RE CIP
(0 5/0
7)

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