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*Households with actual, unreimbursed disaster-related expenses equal to or greater than $100 qualify for Disaster Standard Expense Deduction. Households with countable disaster-related expenses that fall below the $100 threshold should have the eligibility determined using actual expenses.

AGENCY USE ONLY

DISASTER ALLOTMENT CALCULATION

1. Anticipated Income $___________

2. Disaster Income Limit: HH Size ___________ $___________

• INELIGIBLE if #1 is greater than #2

3. Resources $___________

• INELIGIBLE if #1 plus #3 is greater than #2

4. Total Disaster related expenses* $ ___________

• INELIGIBLE if #1 plus #3 minus #4 is greater than #2 • ELIGIBLE if household meets the income test (#1 plus #3 minus #4 is less than or equal to #2)

• WITHDRAWN on: ______________________ • DENIED because: ________________________________________ • APPROVED on: _____________________ • DISASTER ALLOTMENT AMOUNT: $_____________

WORKER: _____________________________ Date: ____________________

DEPENDING ON THE DISASTER, CALCULATION FOR CURRENTLY CERTIFIED HOUSEHOLDS

1. DISASTER ALLOTMENT AMOUNT $___________

2. Ongoing Allotment (prorated) minus $___________

3. Difference (1 minus 2)

$___________

4. Amount of Food Loss plus $___________

5. DISASTER ALLOTMENT AMOUNT (3 plus 4) $___________

WORKER: _____________________________ Date: ____________________