Food Stamp Budget Work Sheet For Households With Elderly (60 Or Over) Or Disabled Member - State Of Alaska Department Of Health And Social Services

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State of Alaska
Department of Health and Social Services
Division of Public Assistance
FOOD STAMP BUDGET WORK SHEET
For Households with Elderly (60 or Over) or Disabled Member
Reset Form
PART I: Find Net Income
Case Number (Optional)
Case Name (Optional)
A.
Household Size
(A)
B.
Gross Monthly Earned Income
(B)
Subtract Earned Income Deduction (20% of Earned Income) (B ÷ 5)
C.
(C)
–
D.
Net Monthly Earned Income ( B – C)
=
(D)
E.
Add Other Unearned Income (SSI, Social Security, Pensions, TA, GA, UIB etc.) +
(E)
F.
Subtotal Monthly Income (D + E)
=
(F)
G.
Subtract Standard Deduction ($256 for HH of 5 or less, $268 for HH > 5)
–
(G)
H.
Subtotal (F - G)
=
(H)
Enter the total allowable medical costs here:
I.
Subtract Medical Costs over $35 (Total medical cost - $35)
–
(I)
J.
Subtotal (H – I)
=
(J)
K.
Subtract Dependent Care Costs
–
(K)
L.
Subtract Child Support Deduction (Actual amount expected to be paid)
–
(L)
M.
TOTAL ADJUSTED INCOME [J – (K + L)]
=
(M)
Central (CE)
FIND MONTHLY SHELTER COSTS:
Select Region:
1. Rent/Mortgage
2. Insurance on Home
3. Property Tax
(a) Subtotal 1 thru 3
(a)
4. Garbage Collection
5. Heating Fuel
If household incurs heating fuel cost, use SUD.
Check this box to use the SUD -->
6. Telephone
If household does not incur heating fuel costs, use the
7. Electricity
Non-heating utility standard (NHUS) for 6 – 9.
8. Water
9. Sewer
(b) Subtotal SUD or total 4, 6, 7, 8, 9
(b)
N.
TOTAL MONTHLY SHELTER COSTS (a + b)
=
(N)
Subtract ½ OF Total Adjusted Income (M ÷ 2)
O.
(O)
–
P.
Excess Shelter Costs (N – O)
=
(P)
Enter Total Adjusted Income (M)
(M)
Subtract Excess Shelter Costs (P)
–
(P)
MONTHLY NET INCOME (M – P)
=
Q
(Q)
Calculate Net Income
Automated FSP 74 (06-3828) (Effective 10/2012 through 9/2013)
Alaska FS Manual Addendum 7
Page 1

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