Form Mc 175-4 - Sneede V. Kizer Mini Budget Units And Share Of Cost Determinations / Property Determinations Page 2

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MBU # _______
MBU # _______
Person Name/Number
Orig Net
Property
Person Name/Number
Orig Net
Property
Aid Nonexempt
Income
Aid Nonexempt
Income
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
7.
7.
8.
8.
9.
9.
10.
10.
TOTAL
TOTAL
MBU's
Property Limit
MBU's
Property Limit
Maintenance Need
Maintenance Need
(Check one)
(Check one)
Excess Property
Excess Property
Share of Cost for
Share of Cost for
(Check one)
(Check one)
property-eligible persons
property-eligible persons
Rounded Share of Cost
Rounded Share of Cost
If SOC, is there an eligible pregnant woman or child under 19 in MBU?
If SOC, is there an eligible pregnant woman or child under 19 in MBU?
No; stop here.
No; stop here.
Yes; go to MC 175-5
Yes; go to MC 175-5
MBU # _______
MBU # _______
Person Name/Number
Orig Net
Property
Person Name/Number
Orig Net
Property
Aid Nonexempt
Income
Aid Nonexempt
Income
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
7.
7.
8.
8.
9.
9.
10.
10.
TOTAL
TOTAL
MBU's
Property Limit
MBU's
Property Limit
Maintenance Need
Maintenance Need
(Check one)
(Check one)
Excess Property
Excess Property
Share of Cost for
Share of Cost for
(Check one)
(Check one)
property-eligible persons
property-eligible persons
Rounded Share of Cost
Rounded Share of Cost
If SOC, is there an eligible pregnant woman or child under 19 in MBU?
If SOC, is there an eligible pregnant woman or child under 19 in MBU?
No; stop here.
No; stop here.
Yes; go to MC 175-5
Yes; go to MC 175-5
Eligibility Worker signature
Worker number
Date of computation
MC 175-4 (05/07)
Page 2 of 2

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