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□ □ □ □ □ □ MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES HEALTH INSURANCE WORK ADVANCEMENT (HIWA) BUDGET Case Name Case Number Date Worker FINANCIAL ELIGIBILITY INCOME MONTH: I. GROSS COUNTABLE INCOME TEST A. UNEARNED INCOME *GROSS – RSDI ................................................................... Railroad Retirement .......................................... Veteran Benefits ................................................ Pension / Retirement......................................... Contributions..................................................... Other ................................................................. Total Countable Unearned Income..........................$ GROSS UNEARNED INCOME LIMIT...........................$ ELIGIBLE YES NO B. EARNED INCOME Gross Earnings .................................................... GROSS EARNED INCOME LIMIT .............................. $ ELIGIBLE YES NO II. NET INCOME TEST A. UNEARNED INCOME 1. Total.......................................................................... $ LESS (a) General Income Exclusion ................................... 2. Net Countable Unearned Income ............................. $ B. EARNED INCOME 1. Gross Earnings .......................................................... $ LESS (a) Remaining General Exclusion ................................. – (b) Earnings Exclusions ................. – 65.00 (c) Remaining Earned Income.................................... (d) Less 1/2 of 1(c) 2. Countable Net Earned Income.................................... LESS Total Employment Related Disregards....................... 3. Net Countable Earned Income TOTAL COUNTABLE NET INCOME ...................................$ (Sum of A-2 and B-3) COMBINED NET INCOME LIMIT $ (COUNTABLE) – 20.00 – ELIGIBLE YES NO APPENDIX F MAABD BUDGETS HIWA BUDGET Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25