Temporary Assistance Budget Worksheet Template

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CASE NAME: ___________________
STATE OF ALASKA
CASE NO.: ___________________
DEPARTMENT OF HEALTH & SOCIAL SERVICES
DIVISION OF PUBLIC ASSISTANCE
TEMPORARY ASSISTANCE BUDGET WORKSHEET
Household Type:
Household Size
Benefit Month/Year: ____________
Pregnant Woman
_______
Adult Included
_______
Prospective Budgeting
_______
Incapacited Parent
_______
Retrospective Budgeting
_______
Adult Not Included
_______
(only for benefit months before 10/01)
PROSPECTIVE ELIGIBILITY DETERMINATION
185% ELIGIBILITY TEST
NET INCOME ELIGIBILITY DETERMINATION
EARNED INCOME
EARNED INCOME
Gross Wages
$ ___________
Gross Wages
$ ___________
Adjusted Gross Self-
Adjusted Gross Self-
Employment Earnings
+$ ___________
Employment Earnings
+
$ ___________
In-Kind Earnings
+$ ___________
In-Kind Earnings
+
$ ___________
Total Gross Earned Income
$ ___________
$90 Work Expense
-
$ ___________
Note: Earned Income Deductions are not allowed in
OR
the 185% test.
$150 and _____%
-
$ ___________
Child Care Deduction -
$ ___________
A. GROSS EARNED INCOME
$ ____________
A. NET EARNED INCOME
$ ___________
B. UNEARNED INCOME
+
$ ____________
B. UNEARNED INCOME
+
$ ___________
C. CHILD SUPPORT PAID -
$ ___________
C. NET DEEMED INCOME +
$ ____________
D. NET DEEMED INCOME +
$ ___________
Total Gross Income (A+B+C)
$ ____________
Net Countable Income
$ __________
(A+B-C+D)
185% Eligibility Standard
$ ____________
Family's Need Standard
$ ___________
Penalty Amount
-
$ ____________
Penalty Amount
- $ ___________
Penalty amount may vary depending on penalty type
Penalty amount may vary depending on penalty type
and length of penalty period. See TA MS 723-4.
and length of penalty period. See TA MS 723-4.
Adjusted 185% Standard
$ ____________
Adjusted Need Standard
$ ___________
Is Total Gross Income equal to or less than the
Is Net Countable Income equal to or less than
Adjusted 185% Standard _____YES _____ NO
the Adjusted Need Standard?____YES ___NO
If yes, continue to Net Income Eligibility Test.
If yes, complete the Payment Determination Calculation
If no, deny/close case
If no, deny/ close case
TA 3 (06-3060) Rev 12/04
Page 1

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