Form Mc 175-3 P - Sneede V. Kizer Property Work Sheet printable pdf download

State of California—Health and Human Services Agency

Department of Health Care Services

SNEEDE V. KIZER

PROPERTY WORK SHEET

Case name

County district

County use

Case number

Effective date

Mo.

Yr.

INSTRUCTIONS:

•

List all nonexempt property from MC 176 P.

•

If property is owned by more than one person, equally divide the net market value by the number of owners unless evidence is provided to

rebut the division.

•

Joint bank accounts: If available to anyone in the MFBU, do not count the money in a joint account against the MFBU more than once.

Equally prorate the bank account among the owners in the MFBU (subject to rebuttal).

•

Other real property (ORP) must be evaluated to determine if the utilization requirement is met. The $6,000 exemption for utilized ORP

may be spread out over multiple pieces of utilized ORP to maximize eligibility for the multiple mini budget units.

•

If excess property is determined for only some of the mini budget units and Medi-Cal is needed for someone in a property-ineligible mini

budget unit, the Eligibility Worker (EW) may need to exempt a different vehicle or spread the $6,000 exemption in a different manner to

determine if eligibility can be established for the property-ineligible mini budget unit.

•

Motor Vehicle and $6,000 Utilized Other Real Property Exemptions:

•

The MFBU of a MARRIED couple or SINGLE PARENT is allowed only one of each exemption.

•

Each UNMARRIED partner is allowed one of each exemption. His/her exemption may be passed on to a natural/adopted child if the

unmarried parent has no such property or wishes to pass the exemption on to his/her child. However, both unmarried parents cannot

pass on their exemptions to the same mutual child.

•

A CARETAKER RELATIVE who chooses to be in the same MFBU with the children for whom care is provided is allowed one set of

exemptions. In addition, the CHILDREN for whom care is provided are allowed one set of exemptions as a group.

I. ALLOCATION FROM SPOUSE/PARENT

1. For a married couple, enter their total community property in Column II. Enter each spouse’s separate property in Column III.

2. For an unmarried couple or a single parent, enter their separate property in Column III; leave Column II blank.

III. Separate Property

List exempt property

I. List only the Parent’s Nonexempt

II. Community

and name of owner:

Property

Parent A

Parent B

1. Nonexempt Other Real Property

2. Checking

3. Savings

4. CSV of nonexempt life insurance

5. Cash

6. Nonexempt Vehicle

7. Other

10.

11. Subtotal Net Nonexempt Property

12. Enter each spouse’s share of community property.

(Divide line 11, Column II by 2.)

13. Parent’s total net nonexempt property (Add lines 11 and 12.)

14. Number of persons for whom each parent is responsible

(See totals on MC 175-2.)

(A)

(B)

15. Allocation to each person for whom parent is responsible

(Divide line 13 by line 14.)

enter on line 27

enter on line 28

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MC 175-3 P (05/07)

Form Mc 175-3 P - Sneede V. Kizer Property Work Sheet

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