Form Mc 176 Ma - 1931 - Sec. 1931 Applicant And Recipient Budget Form: For Determining Net Non-Exempt Income And Section 1931 Income Eligibility For Applicants; And For Recipients Under Alternative B

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State
r:J Calt
c
m ia
-
Hea lltl Ard
Human
Servi
ces
Agency
Department of Healltl
Care
Ser.1
ces
SEC. 1931 APPLICANT AND RECIPIENT BUDGET FORM: FOR
DETERMINING NET NON-EXEMPT INCOME AND SECTION 1931 INCOME
ELIGIBILITY FOR APPLICANTS; AND FOR RECIPIENTS UNDER ALTERNATIVE B
CASE NAME
COU NTY DIS
TR
IC
T
I
COU NTY US
E
EFFE CTIVE ELiG
.
DATE FOR
THIS
BUDGET;
o
NEWAPP.
0
REDETERMINATION
0
CHANGE
0
RETRO ELiG.
0
CORRECTION
MONTH:
YEAR:
NAME MFB
U
MEMBER #1
NAME MFB
U
MEMBER #6
OTHER COVERAGE
NAME MFB
U
MEMBER #2
NAME MFB
U
MEMBER #7
NAME MFB
U
MEMBER #3
NAME MFB
U
MEMBER #fJ
NAME MFB
U
MEMBER
#4
NAME MFB
U
MEMBER #9
NAME MFB
U
MEMBER #5
NAME MFB
U
MEMBER#10
tota
l
mfb
u
UNEARNED
INC
CME
MFBU
MEMBER
#
UNEARNED
INC
CME
MFB
U
MEMBER
#
-
-
uneaned
,
•
,
•
ENTER NON-E XEMPT UNEARNED
INCO
ME OF
Incom
e
:
1
EACH MFB
U
MEMBER
,
THEN TOTAL
FOR
MFB
U
UNEARNED
INC
CME
MFBU
MEMBER
#
UNEARNED INC
CME MFB
U
MEMBER
#
(DO NOT
INCLUDE
DISABILITY INCOME
HERE)
-
-
,
,
•
,
•
2
o
ED UCATIONAL EXPENSE
(§
50547
)
EXEMPT INCOME
(LIST
EXEMPT
INCOME
HERE
)
·
,
3
0
$
50
SUPP ORT RE CEIVED
(§505
54
.5)
·
,
BOX
4
4
REMAINING NON-EXEMPT UNEARNED INCOM:
-,
tota
l
mfbu
ce,
OF MFB
U
MEMBER #
ce,
OF MFB
U
MEMBER
#
dis
ab
ility-
based
-
-
ENTER
NON-
EXEMPT
DISABILITY
INCO
ME
(O BI)
Income
,
•
,
•
OF EA CH
MFB
U
MEMBER
,
THEN TOTAL
FOR
,
5
MFB
U (DO
NOT
ENTER
SO
l
&
TW
C
HERE
ce,
OF MFB
U
MEMBER #
-
:
ce,
OF MFB
U
MEMBER
#
-
BE CA
USE
THE
Y
ARE
CO
NS IDERED
EARNINGS)
,
,
•
,
•
:
6
$240
DEDUCTION
-
$
240
7
REMAINING NON-EXEMPT DISABILITY INCOME
BOX 7
(OB
I) (I
F
DEDUCTION
EXC
EEDS
DISABILITY
BASED
INCO
ME, ENTER
-0-)
-,
earn
ings,
mfbu
earn
in
gs
,
mfbu
ea
rnings,
mfb
u
ea
rnings,
mfbu
memb er
8
ENTER EARN INGS CF EA CH MFB
U
MEMBER,
m
e
m
~
r#
- ­
member#
- ­
mem
ber#
- ­
,
- ­
SUBTRA CT
$
90
W
ORK EXPENSE DED
UC
Tl ON
tota
l
mfb
u
,
FR OM EA
CH,
T11EN TOTALREMA.lNDERS FOR
eam
lng
s
,
,
,
MFB
U
-
$9
0
WRK EXP
OED
-
$9
0
WR
K
EXP
OED
-
$9
0
WRK EXP
OED
-
$90 WR
K
EXP
OED
,
-,
-
,
-
,
-,
9
o
DE
PEN
DENT
CARE
DEDUCTION
(§5055 3.5)
,
"
o
ALLOCAT ION
TO EXCLUDED
CHILDREN
(§50558)
.
,
10
BOX
10
o
ALLOCAT ION
TO
PA FAM
ILY
MEMBER
REMAINING NON-EXEMPT EARNED INCOME
-$
"
(§50557)
..
TOTAL REMAINING INCOME: NON-EXEMPT
TOTAL NFBU NET NON-EXEM'T INCOME
11
UNEARNED INCOME
&
NON-EXEM'T EARNED
"
INC OM: (LINES 4
+
7
+
10)
,
(R
OJN
DED DCMlN
TO
THE NEAREST
DOLLAR)
-
,
12
,
(ENTER
o
CHILD/SPOU
SAL SUPP ORT PYMTS
(§505
54
)
"
SEC.
1931
FPL
INCCME
LIMIT FOR FAMILY
FPL INCO
ME
LIMIT APPROPRIATE
·
,
FOR FAM
ILY
SIZE
HERE
)
IF
INCO
ME FR OM LINE 15 IS LESS THAN OR
o
N OT ELIG IBLE
IF
NO
SNEEDE
ELIG IBLE CLASS MEMBER, EVALUATE
FOR
OTHER MED I--CAL
EQ UAL
TO
LIM IT FR OM LINE
16,
FAM
ILY IS
o
ELIG IBLE
PR
OG
RAMS; IF
SNEEDE -ELI
GIB
LE
CLASS MEMBER
,
EVALUATE FOR SE
C
1931 UNDER
INCO
ME ELIG IBLE
SNEEDE
ELIG
IBILI TY
W
ORKERS
SIGNATURE
wor1{er
number
CO
MP
U
TATl ON
DATE
COU NTY
USE
MC
176 MA
-
1931
Grouj}-AP
PL-PE
CI
P (05/07)

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