Page 14

self-employment using the full calendar month preceding the date of the application. C) Unemployment Insurance benefits; D) Social Security, Veterans Administration, or retirement benefits; Note: Expenses related to Medicare (such as premiums) should be subtracted when determining gross income. E) Alimony, spousal maintenance, child support, or other such income; or F) Other monies coming into the Household. iii. Documentation must show that the Household’s monthly income is less than 60% of the SMI or 150% of the FPL (whichever is greater, see Appendix A). Documentation may include, but is not limited to: A) Pay stubs or employment verification letter covering the 30 days prior to and including the date of application; B) Tax documents for the previous calendar year, except when the Applicant indicates the documents do not reflect the Applicant’s current income: 1) Form 1040 or 1099, plus Schedule C (Profit and Loss Statement) for self-employment; 2) Form 1099-R for retirement distributions. C) Self-Employment Income Statement form (DCAD-1004A & DCAD-1004A-S); or D) Award letters (e.g., SSI, SSDI, or Social Security). iv. If an Applicant does not have the most recent pay stubs for all members of the Household, the Applicant shall provide other evidence of income amounts for all Household Members who receive income. v. Household monthly income for the purpose of determining eligibility and benefit amount is calculated using the following formula: A) ([Average Gross Income per Pay Period X Income Frequency] / 12) 14 of 41