HI 03094.405 Income Worksheet
The Income Worksheet is a listing of the applicant’s types of income, the amount of the income, and the total countable income. It is generated as an attachment to the following subsidy notices: Award, Denial, Pre-Decisional, Change, Planned Action, Termination, and Redetermination-SSA initiated. An Income Worksheet is not generated if the applicant has no income. The Income Worksheet is generated by MAPS.
B. Sample Income Worksheet
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___
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.
Choice 1: your
Choice 2: your and your spouse’s
month and year of application using format “January 2006”
(date can be no earlier than January 2006)