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State of Maryland Medical Assistance Manual Revised April 2014
DEPENDENT ALLOWANCE WORKSHEET
C.I.D. # ________________________
Name ________________________
Date: _______________________
III. Dependent Allowance for ___________________________________________
Medically Needy Income Level
$_____________________
Monthly Income:
Social Security __________________
V.A. Benefits __________________
Earned Income __________________
Other
__________________
Total Monthly Income
- ______________________
Dependent Allowance
$ ______________________
DES 601B (LTC) 11/03