Form Mc176-1 - Qualified Medicare Beneficiary (Qmb)/specified Low-Income Medicare Beneficiary (Slmb)/qualifying Individual (Qi) Eligibility Work Sheet For All Applicants: Individual(S), Couple(S), And Child(Ren) (Ltc Individual In Own Mfbu) Page 3
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41.
Enter: Social Security income.
2.
Net income received from property.
3–4.
All other unearned income. If applicable, include SSI/SSP, In-Home Supportive Services (IHSS) recipients’ available
income (from the MC 176 W, Part II), and income allocated from the Pickle-eligible spouse or parent.
5.
Total the amounts in Section I, Part A, lines 1(a) through 4(a). This is the total unearned income of the QMB/SLMB/QI
applicant of the MFBU. Also, total the amounts in Section I, Part A, lines 1(b) through 4(b). This is the total unearned
income of the QMB/SLMB/QI spouse; ineligible spouse; or parent of the QMB/SLMB/QI child applicant of the MFBU.
6.
Add lines 5(a) and (b), or enter the amount from MC 176 W, Section VI, Part A. This is the combined unearned
income of the QMB/SLMB/QI ABD applicant in the MFBU and their eligible or ineligible spouse or ineligible parent(s)
of a QMB/SLMB/QI child applicant who is a member of the MFBU.
7.
No entry. This shows the $20 any income deduction.
8.
Subtract line 7 from line 6. This is the total countable unearned income. If the countable unearned income is a minus
figure, enter zero on line 8 and enter the minus figure, which is the unused portion of the $20 any income deduction
in the blank provided on line 13.
B.
Nonexempt Earned Income
When any of the following deductions apply to a person’s income which will be listed in Section I, complete Section VI,
Part B of the MC 176 W instead of line 9:
Student Deduction
Section 50551
$30 Plus One-Third, or $30
Section 50551.1
Work Expenses for the Blind
Section 50551.4
Court Ordered Child/Spousal Support
Gibbins v. Rank
9.
Enter the gross earned income.
10.
Add the amounts in lines 9(a) and (b) or enter the amount from Section VI, Part B, line 4 of the MC 176 W. This is
the combined earned income of the QMB/SLMB/QI applicant(s), QMB/SLMB/QI spouse or parent(s) of the MFBU.
11.
Deduct any impairment related work expenses (IRWE) of the potential QMB/SLMB/QI applicant(s).
12.
Subtract number 11 (IRWE expenses) from number 10.
13.
Enter the $65 or the $65 and one-half deduction plus any unused portion of the $20 any income deduction here.
14.
Subtract line 13 from line 12. If line 14 is less than line 10, enter zero.
15.
Divide line 14 by 2. This figure equals the countable earned income.
16.
Total Part A, line 8 and Part B, line 15, to obtain the total unearned and earned income. Enter this amount in
Section III, line 1.
SECTION II. INCOME OF MFBU MEMBER (BOTH ELIGIBLE AND INELIGIBLE MEMBERS) NOT LISTED IN COLUMN I
NOTE: The ownership of income determination required by CCR, Section 50512, should be determined prior to the completion
of this portion of the form if there is a spouse with LTC status who is in a separate MFBU.
A.
Nonexempt Unearned Income
1.
Enter: Social Security income.
2.
Net income received from property.
Page 2 of 3
MC176-1 QMB/SLMB/QI (05/07)
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