Form Mc 175-3i.1 - Sneede V. Kizer Net Nonexempt Income Determination-Continuation Sheet
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1
2State of California—Health and Human Services Agency
Department of Health Care Services
SNEEDE V. KIZER
NET NONEXEMPT INCOME DETERMINATION—Continuation Sheet
Case name
County district
County use
Case number
Effective date
Month
Year
INSTRUCTIONS
*
Child/spousal support
payments received
Child support is income to the child, not to the parent or caretaker relative.
For AFDC-MN/MI only
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.
For ABD-MN only
Each ABD-MN child for whom absent parent support payments are intended will receive a one-third deduction from this
income.
**
Unearned in-kind income
Prorate the unearned in-kind among the persons who receive the income. Example: MFBU of four receives free housing.
Use in-kind income for four and each person receives one-fourth of the in-kind income. Add an unborn’s share of in-kind
income to the pregnant woman’s share. If the pregnant woman is 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.
***
ABD-MN deductions
Allow each ABD-MN child: $20, any income deduction, and $65 and one-half earned income deduction. Allow each
ABD-MN adult or spouse of an ABD-MN adult, or parent of an ABD-MN child: $20, any income deduction, and $65 plus
one-half earned income deduction.
NOTE: If any of the following deductions apply, complete MC 176W, part VI, before completing Sections A or B.
Educational Expenses
Section 50547
Student Deduction
Section 50551
$30 Plus 1/3
Section 50551.1
Work Expenses for the Blind
Section 50551.4
Income for Self-support
Section 50551.5
ENTER NAME OF EACH MFBU MEMBER
Name
Name
Name
Name
Name
(Do not list unborns)
PERSON TYPE
Child
Child
Child
Child
Child
A. NONEXEMPT UNEARNED INCOME
AFDC-MN/MI and/or ABD-MN
1. RSDI
2. Net income from property
3. *Net child/spousal support received
4. **In-kind income
5. Income available from PA or other PA
(MC 175-6, line A.4.)
6. Other:
7. Other:
8. Total (add line 1 through line 7)
9. ***ABD-MN $20 and any income deduction
(skip if AFDC-MN/MI)
10. Countable unearned income (line 8 minus line 9;
enter on section D, line 16)
Enter computation for child/spousal support and/or unearned in-kind income:
Page 1 of 2
MC 175-3I.1 (05/07)
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