Basic (05-05)

HI 03094.405 Income Worksheet

A. Purpose/Use

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___



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.






  1. 1) 

    Choice 1: your

    Choice 2: your and your spouse’s

  2. 2) 

    month and year of application using format “January 2006”

    (date can be no earlier than January 2006)


To Link to this section - Use this URL:
HI 03094.405 - Income Worksheet - 05/24/2005
Batch run: 07/08/2013