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LIFE INSURANCE Y N (NOT APPLICABLE FOR SNAP)

PROGRAM(S)

MBR

OWNER

TYPE

FACE $

CASH $

COMPANY ACCT#

VERIFICATION

01

COUNTABLE

6. TRANSFER OF RESOURCES Y N (MEDICAID: ALSO EVALUATE TRANSFER OF INCOME)

MBR

TYPE, DATE

VALUE

AMOUNT $

VERIFICATION, CALCULATION OF PERIOD OF INELIGIBILITY

SNAP

TANF

MED

7. EARNED INCOME Y N

PROGRAM(S)

MBR

INCOME SOURCE

DATE REC’D

AMOUNT

FREQUENCY

HRS/WK

VERIFICATION

COUNTABLE

8. UNEARNED INCOME Y N

PROGRAM(S)

MBR

INCOME SOURCE

DATE REC’D

AMOUNT

FREQUENCY

VERIFICATION

COUNTABLE

VEC Match No Match Date SOLQ-I SVES Match No Match Date APECS Match No Match Date CALCULATIONS (DOCUMENT DISREGARDS, INCOME SCREENINGS, SELF EMPLOYMENT EXPENSES, SCHOOL EXPENSES, CHILD SUPPORT)

APPLICATION FOR OTHER BENEFITS: ( ) SSA ( ) SSI ( ) UCB ( ) VA ( ) OTHER

TOTAL COUNTABLE RESOURCES

TOTAL COUNTABLE INCOME

SNAP

TANF

MEDICAID

SNAP

TANF

MEDICAID

$

$

$

$

$

$

$

$ 3