Free Uniform Cost Sharing Plan - Spousal Support for Facility Residents - Wisconsin


File Size: 11.3 kB
Pages: 3
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 1,280 Words, 4,389 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f29324.pdf

Download Uniform Cost Sharing Plan - Spousal Support for Facility Residents ( 11.3 kB)


Preview Uniform Cost Sharing Plan - Spousal Support for Facility Residents
DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29324 (01/2009)

STATE OF WISCONSIN

UNIFORM COST SHARING PLAN
SPOUSAL SUPPORT FOR FACILITY RESIDENTS
GROSS MONTHLY INCOME from to

0 1826 1851 1876 1901 1926 1951 1976 2001 2026 2051 2076 2101 2126 2151 2176 2201 2226 2251 2276 2301 2326 2351 2376 2401 2426 2451 2476 2501 2526 2551 2576 2601 2626 2651 2676 2701 2726 2751 2776

1825 1850 1875 1900 1925 1950 1975 2000 2025 2050 2075 2100 2125 2150 2175 2200 2225 2250 2275 2300 2325 2350 2375 2400 2425 2450 2475 2500 2525 2550 2575 2600 2625 2650 2675 2700 2725 2750 2775 2800

| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

PERSONS LIVING IN FAMILY 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 14 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

F-29324 Page 2

UNIFORM COST SHARING PLAN
SPOUSAL SUPPORT FOR FACILITY RESIDENTS
GROSS MONTHLY INCOME from to

2801 2826 2851 2876 2901 2926 2951 2976 3001 3026 3051 3076 3101 3126 3151 3176 3201 3226 3251 3276 3301 3326 3351 3376 3401 3426 3451 3476 3501 3526 3551 3576 3601 3626 3651 3676 3701 3726 3751 3776

2825 2850 2875 2900 2925 2950 2975 3000 3025 3050 3075 3100 3125 3150 3175 3200 3225 3250 3275 3300 3325 3350 3375 3400 3425 3450 3475 3500 3525 3550 3575 3600 3625 3650 3675 3700 3725 3750 3775 3800

| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

PERSONS LIVING IN FAMILY 1 21 28 35 42 49 56 63 70 77 84 91 98 105 112 119 126 133 140 147 152 154 156 158 159 161 163 165 166 168 170 172 173 175 177 179 180 182 184 186 187 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 11 18 25 32 39 46 53 60 67 74 81 88 95 102 109 116 123 130 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

F-29324 Page 3

UNIFORM COST SHARING PLAN
SPOUSAL SUPPORT FOR FACILITY RESIDENTS
GROSS MONTHLY INCOME from to

| | | |

PERSONS LIVING IN FAMILY 1 2 3 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 14 21 28 35 42 49 56 63 70 77 84 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3801 3826 3851 3876 3901 3926 3951 3976 4001 4026 4051 4076 4101 4126 4151 4176 4201 4226 4251 4276 4301 4326 4351 4376 4401 4426 4451 4476 4501 4526 4551 4576 4601 4626 4651 4676 4701 4726 4751 4776

| 189 137 0 | 191 144 0 | 193 151 0 | 194 154 0 | 3925 | 196 155 2 3950 | 198 157 9 3975 | 200 159 16 4000 | 201 161 23 | 4025 | 203 162 30 4050 | 205 164 37 4075 | 207 166 44 4100 | 208 168 51 | 4125 | 210 169 58 4150 | 212 171 65 4175 | 214 173 72 4200 | 215 175 79 | 4225 | 217 176 86 4250 | 219 178 93 4275 | 221 180 100 4300 | 222 182 107 | 4325 | 224 183 114 4350 | 226 185 121 4375 | 228 187 128 4400 | 229 189 135 | 4425 | 231 190 142 4450 | 233 192 149 4475 | 235 194 153 4500 | 236 196 155 | 4525 | 238 197 156 4550 | 240 199 158 4575 | 242 201 160 4600 | 243 203 162 | 4625 | 245 204 163 4650 | 247 206 165 4675 | 249 208 167 4700 | 250 210 169 | 4725 | 252 211 170 4750 | 254 213 172 4775 | 256 215 174 4800 | 257 217 176 For income over $4,800, use last value in column plus 7% of income over $4,800.

3825 3850 3875 3900