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FOOD STAMP HANDBOOK
Handbook FORMS AND INSTRUCTIONS ___-83:1290 (Cont) | 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230
DFA 285-B (12/83) -
State of Catifornia Deperiment of Social Services Haalth and Welfare Agency
FOOD STAMP BUDGET WORKSHEET
TASE NAME
“ASE NUMBER COMPANION CASE AFIERF ACE CLASSIFICATION
NA pa OD men CERIiEATiON SSURNCE MONTH TESUANCE MONTH PeAioD ROM EHHOUGH ' " i
PART 1 - GROSS INCOME ELIGIBILITY. A. NONEXEMPT GROSS EARNED INCOME 1. Gross Salary, Wages 6
DOCUMENTATION
2. Sall-Employment
3, Training Allowance
A. Tota! Gross Earnad Incoma {Al + A2 + A3} $ B. NONEXEMPT GROSS UNEARNED INCOME 1, Cash Aid $
. Sociat Security, UIB, DIB, Pensions Child/Spousal Support
. Scholarships, Grants, Loans
. Other
DeEERON
Total Gross Unaarned income(#1+B2+83+84+B5 8, Cc. GROSS INCOME TEST 1, Household Size 2. Maximum Gross income Allowed (rom Table} 8, 3, Totat Gross Monthly income (A4 + 86} ES
$ 4, Gross Income Etigibia? (is C3 teas than or equal to 2?) i 3 ve Lb n0 Tver UT vo
PART 2. NET INCOME ELIGIBILITY () Prospective ©) Retrospective§O) Prospective C) Retrospective B. INCOME {For Prospective Budgets Only}
1. Adjusted Gross Earned income {82% of Ad) &
2. Total Nonexempt Gross income (86 + D1) 6
£. NONEXEMPT GROSS EARNED INCOME (For Retrospective Budgets Oniy} 1, Gross Salary, Wages 8
2. Selt-timpioyment 3, Training Aliowance 4, Totat Gross Earned income (Et + E2 + £3} ¢
5. Adjusted Gross Earned Income (82% of £4} %,
NONEXEMPT GROSS UNEARNED INCOME (For Retrospective Budgets Oniy) 1, Cash Aid 6.
2. Social Security, LIB, DIB, Pensions 3, Child/Spousal Support
4, Scholarships, Grants, Lonns
5, Other
8. Tota! Gross Linsarned income (Ft + F2 + F3 + Pa + FB} $, 4, 7. Total Nonexempt Grogs Income (E5 + F6) $, &,
G. STANDARD/OEPENDENT CARE DEDUCTION 1, Standard Deduction &,
2, Depandent Care (Lesser of Actual or Maximum} 3. Total Deductions (G1 + G2) t, 4, Total Adjusted income (D2 - G3 or F7 - G3} %,
H. SHELTER DEDUCTION (if G2 is at Maximum. aki BY TMe and entero mig) O72 8¢ Maximuens akin
1. Total Housing Costs ‘ ‘ 2. Tota! Utility Coats (Actual or SUA t ’ 3, Total Shetter Costs ¢ t 4, Allowable Shalter Costs (50% of G4} 6 ' 6, Excess Shelter Costs (H3 - H4)
6. Maximum Allowance for Shelter/Depandent Care 7, Dependent Care Deductian (from G2) ‘ 6 8. Maximum Sheiter Deduction (N6 » 17}
8. Atfowable Shelter Deduction (Lesser of HE or HB)
. |, NET MONTHLY INCOME (G4 - Ha) in ] fe |
NET INCOME TesT . \ 1. Household Size
2. Maximum Net income Aliowed (from Tabi]
§.
a 4
m
uy
First-Month Benefits ' § Proeat ' 3, Net income Eligibleijfis Less than or equal to J2?)i im Yes. al Ko im Yas a No. Ores ONo PART 3+ BENEFITS aa wee [somata [eerenent EW. initlals/Date * DFA 286-8 (12/83) Aequired Form « Substitutes Permared
Rev. 1359 replaces . CALIFORNIA-DSS-MANUAL-SS MY cue 2131 Effective 2/15/84