Example Income Calculation Worksheet Page 7
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8Example Income Calculation Worksheet (Optional)
This worksheet is to assist you in calculating the income values to enter on the SeniorCare Application. This worksheet is yours to keep. On the
SeniorCare Application enter whole dollar amounts, no cents. See Section IV of these instructions for descriptions of the income types.
Gross Social Security
Applicant
Spouse
1. Monthly Social Security amount: (include
$__________ x 12 months = ___________
$__________ x 12 months = ___________
Electronic Fund Transfers)
2. Medicare Part B premium (if withheld from
+ $__________ x 12 months = ___________
+ $__________ x 12 months = ___________
your check)
TOTAL Gross Social Security
$__________ x 12 months = ___________
$__________ x 12 months = ___________
Gross Wages
Applicant
Spouse
1. Estimated monthly earnings. Use gross
$__________ x 12 months = ___________
$__________ x 12 months = ___________
amounts shown on your wage statements
(amounts before taxes and deductions).
2. Repeat for all types of earnings you
$__________ x 12 months = ___________
$__________ x 12 months = ___________
receive.
+ $__________ x 12 months = ___________
+ $__________ x 12 months = ___________
TOTAL Gross Wages
$__________ x 12 months = ___________
$__________ x 12 months = ___________
Interest Dividends and Capital Gains
Applicant
Spouse
1. Amount of interest dividend and capital
$__________ x _________ = ___________
$__________ x _________ = ___________
gains you receive times the frequency with
frequency
frequency
which you receive payments during the
year.
2. Add amounts withheld from the payments
$__________ x _________ = ___________
$__________ x _________ = ___________
such as taxes.
frequency
frequency
+ $__________ x _________ = ___________
+ $__________ x _________ = __________
Repeat for all types of interest dividends and
frequency
frequency
capital gains you receive.
TOTAL Interest Dividends and Capital Gains
$__________ x _________ = ___________
$__________ x _________ = ___________
frequency
frequency
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