Form Mc 175-2 - Sneede V. Kizer Responsible Relative Determination

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State of California—Health and Human Services Agency
Department of Health Care Services
SNEEDE V. KIZER
RESPONSIBLE RELATIVE DETERMINATION
(Complete Only if Parent is in MFBU)
Case name
County district
County use
Case number
Effective date
Month
Year
INSTRUCTIONS
1. Complete only when MFBU exceeds Property Limits or has a Share of Cost.
2. Property and Income allocations are only from Spouse to Spouse and from Parent to Natural/Adoptive Child(ren).
3. Complete only Column A when the household consists of only a single parent.
4. Complete Columns A and B in all other situations.
I. Enter name(s) of PARENT/SPOUSE
(A)
(B)
(do not list PA/Other PA).
II. Spouse (leave blank if unmarried).
III. List others for whom Parent/Spouse is responsible. List excluded
and ineligible child(ren). DO NOT LIST UNBORN, PA/OTHER PA.
IV. Total number of persons parent is responsible for—Property
Determination. (Add sections I, II, and III.) Transfer to line I 14 of the
MC 175-3P.
V. Subtract one for Parent A in Column A. Subtract one for Parent B in
Column B.
–1
–1
VI. Total number of persons parent is responsible for—Income
Determination. (line IV minus line V) Transfer to line 28 or line 29 of
the MC 175-3I.
Next, complete the MC 175-3P for Property Determinations or the MC 175-3 I for Share of Cost Determinations.
Eligibility Worker signature
Worker number
Date
MC 175-2 (05/07)

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