Form Soc 294c - Ihss Income Eligibility - Child
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IHSS INCOME ELIGIBILITY - CHILD
NAME
CASE NUMBER
MONTH
PARENT
RECIPIENT
A.
Income deemed to a blind or disabled child living at home who
B.
IHSS share of cost computation for blind or disabled child who
is under 18.
is under 18.
Income of parent and parent's spouse
Unearned
Earned
Unearned
Earned
where neither is aged, blind or disabled.
1.
Gross income
$
$
1.
Income deemed to child
(from A15 or A16)**
$
2.
Allowance for children not blind or disabled
a. Children's needs
2.
Unearned income (list)
(Do not show exempt income)
b. Children's income
$
$
$
c. Net needs (a minus b) $
$
$
a.
$
b.
$
d. Total allowance (add A2c's)
$
c.
$
3.
Remaining unearned income (A1 minus A2d)
$
4.
Unmet children's needs (If A2d is greater
3.
Total unearned income (B1 plus B2)
$
than A1 unearned, enter the difference)
$
4.
Any income exclusion
$ 20
5.
Remaining earned income (A1 minus A4)
$
5.
Net unearned income (B3 minus B4)
$
6.
Any income exclusion
$ 20
6.
Earned income (Do not show exempt income)
$
7.
Net unearned income (A3 minus A6)
$
7.
Unused $20 exclusion (If B4 is greater than
B3, enter the difference)
$
8.
Unused $20 exclusion (If A6 is greater
than A3, enter the difference)
$
8.
Earned income exclusion
$ 65
9.
Earned income exclusion
$ 65
9.
Total exclusions (B7 plus B8)
$
10. Total exclusions (A8 plus A9)
$
10. Remaining earned income (B6 minus B9)
$
11. Earned income (A5 minus A10)
$
11. Net earned income (B10 x 1/2)
$
12. Net earned income (A11 x 1/2)
$
12. Other earned income deductions
$
13. Total income (A7 plus A12)
$
13. Total net earned income (B11 minus B12)
$
14. Allowance for parent and spouse
14. Total countable income (B5 plus B13)
$
(1)
(2)
$
15. SSI/SSP payment level
$
15. Income deemed to child (A13 minus A14)
$
16. IHSS share of cost (B14 minus B15)
$
Income parent(s) where one or both are
**
Note: If more than 1 eligible child, divide deemable income
aged, blind or disabled.
equally among them, except that if one child has exces
16. Parent(s) income in excess of SSI/SSP
income, it is deemed to other eligible children.
payment level (from SOC 294A C)
$
WORKER
DATE
SOC 294C (11/99)
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