Form Mc 175-3i.2a - Section 1931(B) Sneede V. Kizer Net Nonexempt Income Determination And Mini Budget Unit (Mbu) Determination-Applicant
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4State of California—Health and Human Services Agency
Department of Health Care Services
SECTION 1931(b) SNEEDE V. KIZER NET NONEXEMPT INCOME DETERMINATION
AND MINI BUDGET UNIT (MBU) DETERMINATION—APPLICANT
Case name
County district
County use
Case number
Effective date
Month:
Year:
CASE TYPE: APPLICANT OR RECIPIENT USING FEDERAL POVERTY LEVEL (FPL) (ALTERNATIVE B)
PART 1
NOTE: The only deduction applicable to the Section 1931(b) program is the deduction for educational expenses, as provided in Section 50547, Title 22,
California Code of Regulations.
ENTER NAME OF EACH MFBU MEMBER
Name
Name
Name
Name
Name
(Do not list unborns)
Person type
Parent A or
Parent B or
Child
Child
Child
Caretaker
Caretaker
Relative
Relative
A.
NONEXEMPT UNEARNED INCOME
(EXCLUDING DISABILITY-BASED INCOME)
1. Source and amount of nonexempt unearned income*
1
2. Net child/spousal support received
2
3. In-kind income (IKI)
4. Income available from PA/other PA
(see MC 175-6, line A.4.)
5. Total nonexempt unearned income
(add lines 1, 2, 3, and 4)
* Sources include: net income from property, social security nondisability payments, etc.
1 Child/Spousal Support
Child support is income to the child, not to the parent or caretaker relative.
Payments Received
Divide the $50 per month child/spousal support deduction by the number of persons for whom the income is intended.
Any unused remainder will be prorated among the remaining persons who still have support payments to apply against
the deduction.
2 Unearned IKI
Prorate the unearned IKI among the persons who receive the income. Example: Medi-Cal family budget unit (MFBU) of four
receives free housing.
Use IKI for four and each person receives one-fourth of the IKI.
Add an unborn’s share
of IKI to the pregnant woman’s share. If the pregnant woman is Public Assistance (PA)/other PA, and not in the MFBU,
give the unborn’s share to the father of the unborn if he is in the MFBU.
Child/Spousal support and/or IKI computations:
B.
DISABILITY-BASED INCOME
6. Source and amount of disability-based income
7. Section 1931(b) $240 deduction
8. Remaining nonexempt disability-based income
(subtract line 7 from line 6) Enter 0 if negative.
Page 1 of 4
MC 175-3I.2A (05/07) 1931 Group
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