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□ □ □ □ □ □ □ □ _________________________________________ ______________ MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES MAABD BUDGET Case Name Case Number Date Case Manager FINANCIAL ELIGIBILITY I. GROSS COUNTABLE INCOME TEST INCOME MONTH: _______________________________ A. UNEARNED INCOME *GROSS – EXCLUSIONS = COUNTABLE RSDI __________ __________ ___________ Railroad Retirement __________ __________ ___________ Veteran Benefits __________ __________ ___________ Pension/ Retirement __________ __________ ___________ Contributions __________ __________ ___________ Other __________ __________ ___________ Total Countable Unearned Income.................................$___________ B. EARNED INCOME Gross Earnings…………………………………………………………………$___________ TOTAL GROSS COUNTABLE INCOME $___________ GROSS Income Limit………………………………………………………………..$___________ ELIGIBLE……………………………………………………………………………….. YES NO C. DIVISION OF INCOME Customer’s Gross Income...........................................................$___________ Spouse's Gross Income ...............................................................$___________ Total GROSS Community Income ...............................................$___________ Divide Community Income by 2..................................................$___________ Total Countable Income ....................................................$___________ GROSS Income Limit ...................................................................$___________ ELIGIBLE…………………………………………………………………………………. YES NO II. NET INCOME DETERMINATION A. UNEARNED INCOME 1. Total .......................................................................$_________ (COUNTABLE) LESS: (a) General Income Exclusion ................................. – 20.00 2. Countable Unearned Income .................................$_________ B. EARNED INCOME 1. Earnings...................................................................._________ LESS: (a) Remaining General Exclusion ..............................–_________ (b) Earnings Exclusions ................– 65.00 (c) IRWE.......................................– _____ Remaining Earned Income .................................=__________ (d) Less 1/2 of 1(c) ......................-__________ 2. Countable Earned Income.. ........_________ TOTAL COUNTABLE NET INCOME .................................... $_________ (Sum of A-2 and B-2) III. AID CODE DETERMINATION Receiving $30 SSI institutional payment (SS) Countable Net income greater than $30 and less than SSI Payment level. (WB) Countable Net income greater than SSI Payment level up to 142% of payment level. (SI) Countable Net is greater than 142% and less than 300% SSI payment level, County Match. (CM) REMARKS/DOCUMENTATION (Medicare Beneficiary Budget Side 2) APPENDIX F MAABD BUDGETS Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 FINANCIAL ELIGIBILITY