Medical Renewal Form Page 4
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9Case name:
Case number:
Date of request:
Income information
1. Does anyone in your home get money for working?
Yes No
If yes, complete below.
Please tell us about wages, salaries and commissions for this month from jobs. We need to know
about money that has already been paid or that will be paid this month to anyone in your home
who is related to you or your children (including expected children). Use gross income (totals
before taxes and deductions).
You must send proof. Please send a copy of the most recent pay stub, or a pay stub received
within the last 30 days, for each job listed.
Self-employment means you are being paid for doing work, but you don’t have a regular employer
other than yourself who gives you a paycheck and takes out taxes. Perhaps you have your own
company with a separate bank account, or perhaps you do odd jobs for people who pay you
in cash.
Does anyone in your home get money for self-employment?
Yes No
If yes, please complete question two in this section.
Tell us about any money expected from work:
Job 1
Who earns money from this job?
What person, business or agency pays this person?
How many hours
How much gross income will
Does this job pay hourly?
Yes
No
each week?
this job pay? (Fill in below):
If yes, how much each hour? ___________
This job pays:
this month?
next month?
every week
every 2 weeks
every month
Job 2
Who earns money from this job?
What person, business or agency pays this person?
How many hours
How much gross income will
Does this job pay hourly?
Yes
No
each week?
this job pay? (Fill in below):
If yes, how much each hour? ___________
This job pays:
this month?
next month?
every week
every 2 weeks
every month
Job 3
Who earns money from this job?
What person, business or agency pays this person?
How many hours
How much gross income will
Does this job pay hourly?
Yes
No
each week?
this job pay? (Fill in below):
If yes, how much each hour? ___________
this month?
next month?
This job pays:
every week
every 2 weeks
every month
Please use another sheet of paper if you need to write about more jobs.
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?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 4
OHA 0945 (06/12)
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