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State of Maryland Medical Assistance Manual Revised April 2014
SPOUSAL AND FAMILY ALLOWANCE WORKSHEET
C.I.D.# ___________________________
Date:
Name:
I. Spousal Allowance
Monthly Shelter Expenses: Rent/Mortgage
$__________ Property Taxes
___________
Homeowner’s Insurance
___________ Utility Standard
___________ Other
___________
a. Total Shelter Costs
$ ____________ b. Excess Shelter Standard
- ____________ c. Excess Shelter Allowance = ____________ d. Basic Maintenance & Shelter ____________ e. Total of lines c. & d.
____________ f. Maximum Maintenance & Shelter
____________
Lesser of lines e. or f.
$ ____________
Monthly Income: Social Security
____________ V.A. Benefit
____________ Pension
____________ Earned Income
____________ Other ____________________ ____________
Total Monthly Income - ____________
Spousal Allowance
= ____________
II. Family Allowance for ___________________________
Basic Maintenance and Shelter
$ ____________
Monthly Income: Social Security
_____________ V.A. Benefit
_____________ Pension
_____________ Earned Income
_____________ Other
______ _____________
Total Monthly Income
- ____________
Difference
____________
Family Allowance = Difference = __________ = ____________
3 3 DES 601A (LTC) 11/03