Example Income Calculation Worksheet (Page 4 of 8) in pdf

SeniorCare Application Instructions

Page 4

F-10076A (09/11)

DO NOT INCLUDE any income you may receive from any of the sources listed below:

1. Supplemental Security Income (SSI). SSI is a federal income supplement program designed to help

aged, blind or disabled persons who have little or no money.

2. Major disaster and emergency assistance payments.

3. Payments from an Individual Development Account.

4. Reimbursements you receive from expenses incurred either while you worked as a volunteer or expenses

for your job or training.

5. Claims settlement payments approved by federal law for Native Americans.

6. Income or benefits from some special programs including:

• Homestead Tax Credit.

• Low income energy assistance and emergency fuel assistance programs.

• Community service programs such as Retired Senior Volunteer program, Service Corporation of

Retired Executives and Volunteers in Service to America.

• Government subsidy programs for rent, housing or food.

• Federal Emergency Management Assistance (FEMA).

• Agent Orange Settlement Funds.

• The Foster Grandparents Program.

Other similar kinds of income may be excluded. If you have questions, contact the SeniorCare Customer

Service Hotline 1-800-657-2038.

Grand Total (Optional - Estimated 12-month total)

You may enter the grand total of amounts from all income here, but it is not required. If you do not enter the

grand total, it will be calculated for you when the form is received by the SeniorCare program.

Signature of Applicant (SECTION V)

The applicant or applicant’s representative must sign the application form. If you are a representative, legal

guardian or power of attorney who has completed this application form on behalf of someone else, you must

Enrollment Fee (SECTION VI)

If the correct enrollment fee is not enclosed with this form, your SeniorCare enrollment may be denied or

delayed.

Enrollment Fee Enclosed

Shade in the $30 circle if only one person is applying. Shade in the $60 circle if you and your spouse are both

applying for SeniorCare. Enclose the correct dollar amount with the completed application. Payment may be

made by money order, cashier’s check or personal check payable to “State of Wisconsin”. The check or money

order must include the names or each person applying for SeniorCare. DO NOT INCLUDE CASH. If you are

not able to enroll in SeniorCare, your enrollment fee will be returned within 6-8 weeks.

Other Program Information

If you would be interested in other programs such as Medicare Premium Assistance or Foodshare Wisconsin

contact Member Services at 1-800-362-3002. The Medicare Premium Assistance program helps eligible people

pay for Medicare co-insurance and premiums for Part A and Part B. FoodShare Wisconsin helps eligible people

buy food. Additional information will be needed if you decide to apply for these programs.

Example Income Calculation Worksheet Page 4