Example Income Calculation Worksheet (Page 3 of 8) in pdf

SeniorCare Application Instructions

Page 3

F-10076A (09/11)

Shade in the circle that indicates if the address in the Mailing Address Section is your residence, different than

your residence, or the address of your representative, legal guardian or power of attorney.

Expected Annual Income (SECTION IV)

SeniorCare enrollment is based on your income and your spouse’s income if you have a spouse who lives with

you. Enter anticipated income amounts for the next 12-month period. Do not enter monthly amounts.

Provide your best estimate for each of the following types of income (always round to nearest dollar). A

worksheet is included at the end of these instructions to assist you in calculating your income to enter on the

application form.

Gross Social Security (Estimated 12-month total)

Enter expected annual gross Social Security payments for both you and your spouse including Medicare

premiums if they are withheld from your benefit check or any Electronic Fund Transfers.

Gross Wages (Estimated 12-month total)

Enter estimated annual gross salary, wages, bonuses, and commissions (do not include self-employment or

partnership earnings here) received from work for both you and your spouse. Enter the amount before any

deductions are taken out of your earnings. You may use your tax return or W-2 form from last year to estimate

your earnings taking into considering whether or not you expect to work the same amount, more, or less in the

next 12 months. Do not use your adjusted gross income.

Interest and Dividends and Capital Gains (Estimated 12-month total)

Enter estimated annual interest, dividends and capital gains for both you and your spouse. You must include

amounts that are earned even if you do not receive that income. For example, Certificate of Deposit (CD)

interest earned and rolled directly back into the CD principal must be included.

Net Self-Employment Income (Estimated 12-month total)

Enter estimated net annual self-employment income for both you and your spouse. Self-employment includes

farming or a business that you or your spouse owns solely or with others. Deduct your business costs, business

losses, depreciation on business assets and any other deductions the IRS allows you to take on your self-

employment income. You may look at your taxes from last year to get an idea of what you earned and what you

were allowed to deduct. You cannot use a loss in self-employment to offset other types of income. A loss must

be reported as zero.

Retirement Income (Estimated 12-month total)

Enter estimated annual gross pensions, Veterans and Railroad Retirement benefits, taxable portions of

Individual Retirement Accounts (IRAs) and annuities for both you and your spouse that provide regular

periodic payments.

Other Income (Estimated 12-month total)

Enter all other expected annual income for you and your spouse. Other income includes cash assistance,

Unemployment or Workers’ Compensation, alimony payments, support money and rental income minus

operating expenses.

Include any income you receive from a spouse who is not living with you.

Example Income Calculation Worksheet Page 3