Form Mc 175-3 P - Sneede V. Kizer Property Work Sheet Page 2
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1
2State of California—Health and Human Services Agency
Department of Health Care Services
II. ALLOCATION FROM SPOUSE TO SPOUSE (Skip if MFBU does not contain a married couple.)
16. Enter line 15A in both boxes.
$
$
17. Enter line 15B in both boxes.
$
$
18. Total (Add lines 16 and 17.) This is each spouse’s total share of their net
$
$
nonexempt property. (Enter this amount on MC 175-4 in the married couple’s
mini budget unit.)
III. NET NONEXEMPT PROPERTY FOR CHILDREN OR NONPARENT CARETAKER RELATIVE (Do not list unborns.)
1.
2.
3.
4.
5.
Name of Child or Caretaker Relative
Child’s Natural/Adoptive Parent—see Section I
A
B
A
B
A
B
A
B
A
B
(Circle A or B or both.)
List only the child’s or caretaker relative’s
property:
19. Checking
$
$
$
$
$
20. Savings
21. Nonexempt vehicle
22. Nonexempt ORP
23. Other
24.
25.
26. TOTAL
27. Allocation from Parent A*
28. Allocation from Parent B*
29. Net Nonexempt Property
(Add lines 26, 27, 28.) Enter on MC 175-4.
* Enter an allocation from Section I, line 15, only if this is the child’s natural/adoptive parent.
Leave blank if caretaker relative household.
III. NET NONEXEMPT PROPERTY FOR CHILDREN OR NONPARENT CARETAKER RELATIVE (Continued)
6.
7.
8.
9.
10.
Name of Child or Caretaker Relative
Child’s Natural/Adoptive Parent—see Section I
A
B
A
B
A
B
A
B
A
B
(Circle A or B or both.)
List only the child’s or caretaker relative’s
property:
19. Checking
$
$
$
$
$
20. Savings
21. Nonexempt vehicle
22. Nonexempt ORP
23. Other
24.
25.
26. TOTAL
27. Allocation from Parent A*
28. Allocation from Parent B*
29. Net Nonexempt Property
(Add lines 26, 27, 28.) Enter on MC 175-4.
* Enter an allocation from Section I, line 15, only if this is the child’s natural/adoptive parent.
Leave blank if caretaker relative household.
NEXT—COMPLETE MC 175-4
Eligibility Worker signature
Worker number
Date of computation
Page 2 of 2
MC 175-3 P (05/07)
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