Form Mc 176 Ep - Exempt Payment Form
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1State of California—Health and Human Services Agency
Department of Health Care Services
EXEMPT PAYMENT FORM
In some circumstances, payments listed below may be exempt (not counted) as income and/or property when determining
eligibility for Medi-Cal. Some payments may be exempt for a limited period of time from the date of receipt. Be sure to indicate
any of the following that may apply to you or your family. The county will not count the amount of the following payments that
are exempt in the month(s) for which you are requesting Medi-Cal.
Please indicate if you have received any of the following payments and if you have any of the payment left. If so, indicate the
account the payment is in and how much of the payment you still have. Please provide a photocopy of your award letter that
came with your payment or a photocopy of your payment stub.
Yes
No
Type of Payment
How Much is Left
Kept in Which Account
Date Received
Agent Orange payment
Austrian Social Insurance payments
Cash payments for medical or social services
Disaster assistance payment
Payment for lost, stolen, damaged, or destroyed property
Lump sum payment of Social Security or Supplemental
Security income
Funds, payments, or distributions to Native Americans
under federal law
Earned income tax credit
Payment to victims of crime
Relocation assistance
Renter’s credit
Payment of retroactive corrective aid
Payment for children of Vietnam veterans born with spina
bifida
Student loan, grant, scholarship, or fellowship
Japanese or Aleutian reparation payment
Payment to victims of Nazi persecution
Ricky Ray payment
Walker v. Bayer payment
Savings or interest accumulated under an independent
living plan
Earnings of a child saved for a future need
Radiation exposure compensation payment
Allowances, earnings, or payments under the Job Training
Partnership Act
Payment or allowance for home energy assistance,
weatherization, or emergency repair or replacement of
heating or cooling devices
Allowances, earnings, or payments under Title I of the
National and Community Service Act
Housing assistance payments
Cash gift from a tax-exempt organization to a child with a
life-threatening condition (under $2,000 per year)
MC 176 EP (05/07)
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