Page 55

Handbook

"FOOD STAMP HANDBOOK ___FORMS AND INSTRUCTIONS

63-1230 (Cont.)

63-1230 STATE FORMS & INSTRUCTIONS (Continued)

63-7230 DFA 285-D (12/83)

State of California Health and Welfare Agency

FOOD STAMP BU DGET WORKSHEET - Special Medical/Sheiter Deductions

CABE RAE

CASE NUMBER

Department of Social Services

‘COMPANION CASE REFERENCE

GlASBFEATION DLA) eA MIXED,

SERVATION PERIGO

JeROUGH

Hd PART 1 — NET MONTHLY INCOME

12 Prospective C)_Rrrospactive

conth,

O Prospective. €) Retrospective [gangs oe Reinet |

DOCUMENTATION

A,

g

NONEXEMPT GROSS EARNED INCOME 1. Gross Salary, Wages

nN

. Self-Employment

w

» Training Allowance . Tatal Gross Earned income (Al + AZ + A3) . Adjusted Gross Earned income (82% of Ad)

me

NONEXEMPT GROSS UNEARNED INCOME

. Cash Aid

. Social Security, UIB, O18, Pensions

. Child/Spausat Support

. Scholarships, Grants, Loans

. Other

. Tag Sree Uneerned income (81 +82 +83 +B4

MAAR

TOTAL NONEXEMPT GROSS INCOME (A6 + 86}

EXCESS MEDICAL EXPENSES

1. Recurring Expenses

2, One-Month-Only Expenses

3. Averaged Expenses

4, Total Allowsbie Expenses (D4 + D2 + D3) 6. Medical Expense Allowance {#35}

6, Excess Medicel Expenses {04 - D5}

STANDARD /DEPENDENT CARE/MEDICAL DEDUCTIONS

. Standard Oeductian

. Dependent Care (Lesser of Actual of Maximum!

. Excess Medical Expenses (From DS)

. Total Deductions (£1 + E2 + £3) Tors! Adjusted Income {C - Ed}

HELTER DEDUCTION

. Total Housing Costs

Total Utility Coste (Actual or SUA}

. Total Shelter Costs

. Allowabie Shelter Costs (BO% of E5)

. Exeese Sheiter Costs (F3 - Fa}

NET MONTHLY INCOME (ES - F&)

PUN Ma

a

PA!

RT 2 — NET INCOME ELIGIBILITY

H.

NET INCOME TEST 1, Household Size 2. Maximum Nat income Allowed (From Tabie}

3. Net Income Eligibie? (ls G lese then or equal to H27}

CO Yee mi No

oO Yee C) No

PART 3 — BENEFITS

“ALLOTMENT [Pormtenen

ALLOTMENT | BUPPLEMENT

Firet-Month Senafits

EW. initiais/Date

Prorated?

Qves Ono

OFA 286-D{12°B3} Required Furm . Substitutes Permitted

CALIFORNIA-DSS-MANUAL-SS Rev. 1367 replaces Issue 2190

Effective 2/15/84

(MANUAL LETTER NO, 84-13)