Page 5

DHCS Guide for Calculating MAGI Medi-Cal Individual Household Size v1.2 20160826 Household Diagram Worksheets Instructions:  Using Information for each household member to first capture the Household Diagram for all individuals on an application.  Use the other drawing boxes to illustrate, for each individual, the household diagram for each individual. Use a copy this page for more than 8 household members. Application Household Diagram ________Tax filer Household Diagram ________Individual Household Diagram ________Individual Household Diagram ________Individual Household Diagram ________Individual Household Diagram ________Individual Household Diagram ________Individual Household Diagram ________Individual Household Diagram v1.2 2014815