Form Mc 175-3i.1 - Sneede V. Kizer Net Nonexempt Income Determination-Continuation Sheet Page 2
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1
2B. ***NONEXEMPT EARNED INCOME—
Name
Name
Name
Name
Name
ABD-MN or spouse/parent of ABD-MN
11. Gross earned income
12. $65 earned income deductions plus $ _______________
unused $20 from line 9
13. Remainder (line 11 minus line 12)
14. Countable earned income (divide line 13 by 2;
enter on Section D, line 17)
C. NONEXEMPT EARNED INCOME—AFDC-MN/MI ONLY
15. Net earned income (MC 176W, part IV, line 10;
enter on Section D, line 17)
D. TOTAL COUNTABLE INCOME
AFDC-MN/MI and/or ABD-MN
16. Countable unearned income (from line 10)
17. Countable earned income (from line 14 or 15)
18. Income allocated from LTC/B&C person to family
members at home (from MC 176W, part B, or from
MC 175-7, line C.2.)
19. Total countable income (add lines 16, 17, and 18)
E. OTHER DEDUCTIONS
AFDC-MN/MI and/or ABD-MN
20. Health insurance
21. Child support/alimony
22. Income to determine PA eligibility
(MC 175-6, Section B.)
23. Other:
24. Total deductions (add lines 20 through 22)
25. Total net countable income (line 19 minus line 24)
Enter this on MC 175-4 if no parent in MFBU. If parent
in MFBU, continue.
F. PARENTAL/SPOUSAL ALLOCATION COMPUTATION
AFDC-MN/MI and/or ABD-MN (skip if no parent in MFBU)
P/S NEEDS ALLOCATION AMOUNT
26. Child’s natural/adoptive parent. Circle A or B, or both
A
B
A
B
A
B
A
B
A
B
(see MC 175-2).
27. Parent A’s allocation to natural/adopted children
(line 27 from MC 175-3I) Enter in each applicable box.
28. Parent B’s allocation to natural/adopted children
(line 28 from MC 175-3I) Enter in each applicable box.
29. Enter child’s net countable income (from line 25)
30. Child’s total net nonexempt income (add lines 27, 28,
and 29; enter on MC 175-4).
Eligibility Worker signature
Worker number
Computation date
GO TO MC 175-4 NEXT
Page 2 of 2
MC 175-3I.1 (05/07)
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