Form Mc 175-7 - Sneede V. Kizer Allocation Work Sheet Board And Care Person To Spouse And/or Children At Home Or Ltc Person (Afdc-Mn/mi) With No Community Spouse To Children At Home
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1State of California—Health and Welfare Agency
Department of Health Care Services
SNEEDE V. KIZER
ALLOCATION WORK SHEET
BOARD AND CARE PERSON TO SPOUSE AND/OR CHILDREN AT HOME
OR
LTC PERSON (AFDC-MN/MI) WITH NO COMMUNITY SPOUSE TO CHILDREN AT HOME
Case name
County district
County use
Case number
Effective date
Month
Year
INSTRUCTIONS
Complete this form only if Section III on MC 176 W is completed and line 13 of that section shows an amount greater than zero.
A.
NAME OF LTC/BOARD AND CARE PERSON:
________________________________________________
B.
RESPONSIBLE RELATIVE DETERMINATION
List the persons in the MFBU for whom the LTC/Board and Care person
is responsible (do not list unborns, PA/Other PA persons, or excluded persons):
1. Spouse (leave blank if unmarried)
________________________________________________
2. Natural/adopted children
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
3. Total number of persons listed in Sections B.1 and B.2 (do not include the
LTC/Board and Care person):
________________________________________________
C.
ALLOCATION
1. Enter from line 13 of Section III on MC 176 W.
________________________
2. Allocation to each person for whom responsible (divide line C.1 by line B.3)
Enter this amount onto MC 175-3I, Section D, line 18.
________________________
Eligibility Worker signature
Worker number
Date of computation
MC 175-7 (05/07)
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