Form Mc 175-6 - Sneede V. Kizer Allocation From An Ssi Or Ihss Person printable pdf download

Form Mc 175-6 - Sneede V. Kizer Allocation From An Ssi Or Ihss Person

State of California—Health and Human Services Agency

Department of Health Care Services

SNEEDE V. KIZER

ALLOCATION FROM AN SSI OR IHSS PERSON

(INCLUDES ALLOCATION FROM PICKLE PERSON TO MFBU)

Case name

Case number

Effective date (month/year)

Complete this form when there is an income allocation from an SSI, IHSS, or Pickle person to the MFBU, OR the MFBU

has income which is used to determine SSI, IHSS, or Pickle eligibility.

Note: If the MFBU includes either the stepparent or unmarried partner of an SSI or IHSS recipient and that MFBU member’s

income was used to determine SSI or IHSS eligibility of the recipient, the Eligibility Worker will allow that portion of the

MFBU member’s income which was used to determine SSI, IHSS, or Pickle eligibility as a deduction against his/her

own income.

DO NOT TREAT THE UNMARRIED COUPLE AS SPOUSES ON ANY WORK SHEET.

Name of PA/Other PA person

A. Income Available From the SSI or IHSS Person (including income available from a Pickle person to the MFBU)

1. Enter the amount from Section II, line 11 of MC 176 W (If there is income available

$ ____________________

from the Pickle person to the MFBU, enter the amount from line 3, column III, of

the MC 176 M.)

2. Enter the names of the persons in the MFBU for whom the SSI, IHSS, or Pickle

____________________

person is responsible (i.e., spouse and natural/adopted children).

Do NOT list: unborns, any PA/Other PA persons, or excluded persons.

____________________

3. Total number of persons listed in Section A, line 2.

____________________

4. Allocation to each person listed in Section A, line 2. (divide line A.1. by line A.3.).

$ ____________________

Enter this amount on MC 175-3I, Section A, line 5.

B. Income Used to Determine SSI, IHSS, or Pickle Eligibility

(Check here if this section is applicable.)

Enter amount from Section II, line 12 of MC 176 W, on line 22 of the MC 175-3I of the MFBU member whose income was

used to determine SSI, IHSS, or Pickle eligibility.

If two persons have income which is used to determine SSI, IHSS, or Pickle eligibility and the Eligibility Worker is unable to

determine how much of each person’s income was used, divide the income in half AND give each person one-half of the

income deduction. If one-half of the couple does not have sufficient income to fully use the deduction, give the unused

portion of the income deduction to the other person.

Eligibility Worker’s signature

Worker number

Computation date

MC 175-6 (05/07)

Form Mc 175-6 - Sneede V. Kizer Allocation From An Ssi Or Ihss Person