SOCIAL
SECURITY ADMINISTRATION
How
We Counted __1__ Income To
Determine Your Subsidy
For __2__ and
continuing
Social Security $___1___
Railroad Retirement
___2___
Veteran’s Benefits
___3___
Other Pensions or Annuities
___4___
In-Kind Support and Maintenance
___5___
Other Income
___6___
($240 General Income Exclusion)
(___7___)
Subtotal of Your Income We Count $___8___
Wages ___9___
Net Self-Employment Earnings
___10___
Net Loss from Self-Employment ___11___
($780 Earned Income Exclusion) (___12___)
(Impairment Related Work Expenses That We Deduct) (___13___)
(By Law, We Don’t Count Half Of This Amount) (___14___)
(Work Expenses of the Blind That We Deduct) (___15___)
Total of Wages/Self Employment That We Count $___16___
Total Income We Count $___17___
Income limit For Subsidy Eligibility $___18___
NOTE: the 2 following paragraphs should be included when the IRWE or BWE exclusion is present
in the worksheet.
Because you are under age 65 and you have work expenses related to your disability,
we do not count 16.3% of your gross wages when we determine the amount of your income
that we count.
Because you are under age 65 and you have work expenses related to blindness, we do
not count 25% of your gross wages when we determine the amount of your income that
we count.
Fill-in’s
-
1)
Choice 1: your
Choice 2: your and your spouse’s
-
2)
month and year of application using format “January 2006”
(date can be no earlier than January 2006)