Free 49422.FH11 - Indiana

RECORD OF FINANCIAL ELIGIBILITY BUDGET FOR HOOSIER HEALTHWISE
State Form 49422 (2-00) / FI 0005B

County office

The state standard amounts shown on this form are set by State law (IC 12-15-2) and are not meant to show actual needs.

Name of case Address (number and street, city, state, ZIP code) Payee (If other than applicant / recipient) Address (number and street, city, state, ZIP code)

Case number

Application date Effective date

PART I : PERSONS INCLUDED IN ELIGIBILITY DETERMINATION (List in order: caretaker/applicant, spouse, children)
NAME (FIRST) 1. 2. 3. 4. 5. 6. 7. 8. (MIDDLE) (LAST) DATE OF BIRTH APPLYING OR RECEIVING BENEFITS Y OR N SOCIAL SECURITY NUMBER RELATIONSHIP

PART II - DETERMINING ELIGIBILITY SECTION I UNEARNED INCOME NAME OR LINE 1. Benefits (RSDI,UCB, etc.) 2. Deemed income (from parent of a minor) 3. Child Support minus $50 disregard 4. Other (Specify each below) a. b. c. TOTAL UNEARNED INCOME

$

0

$

0

SECTION II - BUDGET COMPUTATIONS SECTION I NET EARNED INCOME NAME OR LINE 1. GROSS EARNED INCOME $ $ 1st Person 2nd Person CATEGORY ALL MED 2 EXCEPT MA F MA F MA Y MA Z 3. DIFFERENCE $ $ MA 2 MA 9 MA N $ $ MA 10

SECTION IV INCOME STANDARDS MANUAL SECTION 3010.25.00 3010.26.00 3010.30.15 3010.30.10 3010.30.05 3010.30.15 3010.30.15 3010.30.20 ICES TABLE TAST TMIS TMIS TMIS TMIS TMIS TMIS TMIS

2. STANDARD WORK DISREGARD

$90.00

$90.00

4. $30.00 DISREGARD (If applicable) (MA C only) 5. DIFFERENCE

$30.00

$30.00

6. 1/3 DISREGARD (Divide Line 5 by 3) (If applicable) (MA C only) 7. DIFFERENCE

$

$

SCRATCH CALCUATIONS / COMMENTS

$

$

8. CHILD CARE DISREGARD

$

$

9. DIFFERENCE

$

$

10. TOTAL UNEARNED INCOME (Part II, Section I, Line 1) 11. TOTAL INCOME

+$

+$

$

$

12. INCOME ALLOCATED TO NONRECIPIENTS COUNTABLE NET INCOME (Subtotal by individual) TOTAL COUNTABLE NET INCOME (Column 1 and Column 2 )

$

$

$

$

$

SECTION III NET INCOME ELIGIBILITY COMPARISON $

1. INCOME STANDARD

2. COUNTABLE NET INCOME (Part II, Section II, last line)

$

3. DIFFERENCE (Subtract Line 2 from Line 1)

$

4. RESULT INCOME DEFICIT - Eligible INCOME EXCESS - Individual eligibility determination must be made

$

.00