Form Dhcs 7021 - California Financial Eligibility Work Sheet - Health And Human Services Agency

State of California—Health and Human Services Agency

D epartment of Health Care Services

FINANCIAL ELIGIBILITY WORK SHEET

(Individual or Couple, Applicant With an Ineligible Spouse)

Case Name

Case Number

Applicant’s Name

PART A.

NEEDS TEST

1. Applicant’s total earned and unearned income (MC 176M, Part I, Line 14): . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

2. Title II COLA disregard amount: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

3. Total countable income (Subtract A.2. from A.1.): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

(If single applicant or couple pass the screening work sheet, proceed to Part F.)

PART B.

INELIGIBLE SPOUSE’S UNEARNED INCOME

1. Ineligible spouse’s total unearned income—do not include public assistance income: . . . . . . . . . . . . . . . . . .

$ _____________

2. Title II COLA disregard amount:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

3. Countable unearned income (Subtract B.2. from B.1.): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

4. Allocation for ineligible children. (If no children, enter zero in B.4.c.)

Do not include Pickle-eligible children.

CHILD #1

CHILD #2

CHILD #3

CHILD #4

Name

Name

Name

Name

a. Allocation (couple Federal Benefit Rate

[FBR] minus individual FBR):

b. Subtract child’s income:

c. Total allocation: . . . . . . . . . . . . . . . . . . .

_________

+ ________

+ ________

+ ________ =

$ _____________

5. Remaining unearned income (Subtract line B.4.c. from B.3.) (If negative, also enter on line C.2.): . . . . . . . .

$ _____________

PART C.

INELIGIBLE SPOUSE’S EARNED INCOME

1. Ineligible spouse’s gross earned income: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

2. Unused portion of allocation for ineligible child(ren): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

3. Remaining earned income (Subtract C.2. from C.1., if negative, enter zero.): . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

PART D.

INELIGIBLE SPOUSE’S TOTAL INCOME AFTER ALLOCATIONS (If B.5. is negative, enter C.3. amount,

otherwise, add B.5. and C.3. and enter.) (If less than the difference between the FBR for a couple and

the FBR for an individual, deeming is not applicable. Make no entry for ineligible spouse’s income

in Part E.): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

PART E.

COMBINED INCOMES (Eligible individual or couple and/or ineligible spouse after ineligible child allocations)

1. Applicant’s gross unearned income (including any applicable ISM-DHS 7044). (If VTR, ISM is zero, use

“household of another” SSI/SSP payment level in F.1.): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ – _ _______________

2. Applicant’s Title II COLA disregard amount: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

3. Applicant’s countable unearned income (Subtract line E.2. from line E.1.): . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

4. Ineligible spouse’s unearned income (line B.5.). (If B.5. is negative, use 0.): . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

5. Combined unearned income (Add lines E.3. and E.4.): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

20

6. Subtract general income exclusion: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ – _ _______________

7. Combined countable unearned income: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

Total Unearned

8. Earned income of applicant and spouse (Use amount from line C.3. for ineligible spouse.): . . .

$ ______________

9. Subtract balance of general exclusion not offset by unearned income (line E.6.): . . . . . . .

$ ______________

10. Remaining earned income: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ______________

65

11. Subtract work expense exclusion: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ –

______________

12. Remaining earned income: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ______________

13. Subtract 1/2 remaining earned income: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ –

______________

14. Countable earned income: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

Total Earned

15. Total countable income (Add lines E.7. and E.14.): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

Combined Total

PART F.

PICKLE ELIGIBILITY CALCULATION

________________

1. Current SSI/SSP payment level for an individual or a couple: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ _____________

2. Enter total countable income (line A.3. or E.15.): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

If line F.2. is less than or equal to F.1., the applicant is Pickle eligible. If ineligible, enter in Tickler System.

Eligibility Worker Signature

Worker Number

Computation Date

County Use

DHCS 7021 (05/07)