Page 8
COMAR 10.09.24.11
1107 State of Maryland Medical Assistance Manual Revised July 2012 Attachment B- Recipient Certificate of Credit/Income
Recipient Certificate of Credit/Income
DATE RECIPIENT CERTIFICATE OF CREDIT/INCOME
INQUIRY
RECIP-ID: 000000000 NAME: D___________
________________________________INCOME_____________________________________
01 COUNTABLE MEMBER INCOME
DATE LAST
NET INCOME SIZE EFF DATE FPL SOURCE TRANS
___________________________CERTIFICATE OF CREDIT___________________________
CERTIFICATE ELIG BEGIN ELIG END
DATE LAST
PRODUCED DATE DATE USED DATE USED SOURCE TRANS 01 062798
060195 123197
3 062798