Line 1 – Enter the unearned income remaining after applying the exemptions and exclusions
in SI SF01210.518.
Lines 2-3 – Self-explanatory.
Line 4 – Enter gross earned income.
Line 5 – If the $7.50 general exclusion has not been completely used on line 2, enter the
remainder.
Lines 6-9 – Self-explanatory. The exclusion is for the recipient only.
Line 10 – Self-explanatory.
Line 11 – Deduct actual work-related expenses for the recipient. For the ineligible spouse,
deduct 25 percent of gross earned unless the spouse provides evidence that the actual
expenses exceed 25 percent.
Lines 12-14 – Self-explanatory.
Line 15 – Skip lines 15-18 if the ineligible spouse is a wife. If the ineligible spouse is
a husband, deduct $200 for his own support.
Line 16 – Subtract Line 15 from Line 14.
Line 17 – If the ineligible spouse is a husband and the amount on Line 16 is a positive figure,
use Form B-2 to determine the allocation for any ineligible minor children who are
not on AFDC/TANF. Enter the result on line 17. If the amount on Line 16 is a negative
figures, enter that amount on Line 18 and go to Line 19 (a) instructions below.
Line 18 – Subtract Line 17 from Line 16.
Line 19 (a) – To determine the amount, if any, allocated to the blind individual:
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1.
If the ineligible spouse is a husband and there is a + remainder on Line 18, enter
in the BI’s column the lesser of Line 18 or one-half of Line 14.
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2.
If the ineligible spouse is a wife, enter in the BI’s column the appropriate amount
from the table on Form B-3.
Line 19 (b) –If 19(a) does not apply, determine the amount if any, allocated to the ineligible
spouse; see SI SF01210.517 on when to use Form B-1. A negative amount on Line 16 of Form B is an indication
that income, if available, can be allocated to the ineligible spouse.
Line 20 – Subtotal: Add Line 19 when income allocated to recipient; subtract the amount on Line 19 when allocating income to spouse.
Line 21 – Enter the remainder of the $7.50 general exemption, if any.
Line 22 – Remainder: Subtract Line 21 from Line 20.
Line 23 – Enter the unexpended income, if any, from the prior month (obtained from Line 28
for prior month).
Line 24 – Add Lines 22 and 23.
Line 25 – Amounts of 50 cents or more are rounded up; amounts of less than 50 cents are rounded
down. Enter the BCI amount on this line as K income on the system or manually compared
to CI/FR.
Line 26 – Enter the Total Allowable Need (TAN) – usually $215.
Line 27 – Subtract Line 26 from Line 25. This figure may be either positive or negative.
If it is negative, ignore the amount for SSI purposes; the recipient would have been
due this amount as his or her grant. If it is positive, countable income exceeds the
Tan and there is unexpended income to carry forward to the next month.
FORM B
Individual With Ineligible Spouse
Name: ________________________________ SSN: ________________________
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PERIOD:
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PERIOD:
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PERIOD:
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PERIOD:
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PERIOD:
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PERIOD:
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LINE 1 Gross Unearned Income
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LINE 2 General Exemption ($7.50)
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LINE 3 Countable Unearned Income (Line 1 minus Line2)
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LINE 4 Gross Earned Income
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LINE 5 Balance of General Exemption (if any)
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LINE 6 Remainder (Line 4 minus Line 5)
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LINE 7 Earned Income Exemption ($85)
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LINE 8 Remainder (Line 6 minus Line 7)
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LINE 9 One-half Remainder (1/2 of Line 8)
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LINE 10 Remainder (Line 8 minus Line 9)
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LINE 11 Work Related Expenses
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LINE 12 Countable Earned Income (Line 10 minus Line 11)
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LINE 13 Countable Unearned Income (Line 3)
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LINE 14 Subtotal Total (Line 12 plus Line 13)
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LINE 15 Spouse’s (husband’s) Exemptions
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LINE 16 Remainder (Line 14 minus Line 15)
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LINE 17 Spouse’s (husband’s) Other Exemptions (from Form B-2)
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Line 18 Remainder (Line 16 minus Line 17
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Line 19 Income Allocated to Recipient (+) or Spouse (-)
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Line 20 Subtotal
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Line 21 Balance of General Exemption (if any)
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Line 22 Remainder (Line 20 minus Line 21)
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Line 23 Unexpended Income from Prior Month
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Line 24 Recipient’s Total Countable Income (Line 22 plus Line 23)
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Line 25 Blind Countable Income (round to the nearest dollar) **
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Line 26 Total Allowable Need (TAN)
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Line 27 Grant Amount (-) or Unexpended Income (+)
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**This amount is the BCI to input as K income or compared manually to the CI/FR.
FORM B-1
Allocation to Ineligible Spouse
Line 1 |
Enter Ineligible Spouse’s Total Allowable Need (TAN) |
$_________ |
Line 2 |
Ineligible Spouse’s Countable Income (Amount from spouse’s Line 14, Form B)
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$_________ |
Line 3 |
Ineligible Spouse’s Unmet Need (Line 1 minus Line 2)
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$_________ |
Line 4 |
Recipient’s Countable Incom (Amount from recipient’s Line 14, Form B)e
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$_________ |
Line 5 |
Allocation to Ineligible Spouse (The lesser of Line 3 or one-half of Line 4)
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$_________ |
Month(s) covered by the above computation __________________________ |
FORM B-2
Ineligible Husband’s Exemption
A. Needs of Minor Children Not Receiving AFDC/TANF
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Line 1 |
Names and birthdates of children under 21: |
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
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Line 2 |
Number of children on Line 1 |
$_______________ |
Line 3 |
Total need from AFDC standard below |
$_______________ |
Line 4 |
Children’s (listed above) gross income |
$_______________ |
Line 5 |
Subtotal (Line 3 minus Live 4) |
$_______________ |
Month(s) covered by the above computation _______________________________
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AFDC Need Standard
Number of Children
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$ Amount
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1 |
115 |
2 |
190 |
3 |
235 |
4 |
280 |
5 |
320 |
6 |
360 |
7 |
395 |
8 |
430 |
0 |
465 |
10 or more |
500 |
B. Other Exemptions (See SI SF01201.516)
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1. Medical expenses of ineligible spouse and minor children
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$_____________ |
2. Payments on Debts
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$_____________ |
3. Unusual current living expenses
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$_____________ |
4. Subtotal
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$____________ |
C. Total Additional Exemption (Add Lines A.5 and B4)
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$____________ |
FORM B-3
*Allocation scale for wife of blind recipient
Wife’s Net Income |
Maximum Contribution |
$ 0-350 351-375
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$ 0 20
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376-400 401-425
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25 30
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426-450 451-475
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35 40
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476-500 501-525
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45 50
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526-550 551-575
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55 60
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576-600 601-625
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65 70
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626-650 651-675
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75 0
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676-700 701-725
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85 90
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726-750 751-775
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95 100
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776-800 801-825
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105 110
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*Use this scale to determine the amount of income allocated to blind recipient (husband)
as described in SI SF01201.516.
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A.
Form C Completion Instructions
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1.
General
Use Form C when both members of an eligible couple are blind recipients converted
in California. The computation is basically the same as the eligible individual’s
computation. Each member of the couple is treated as an individual and has State income
exemptions/exclusions applied. (See Form A completion instructions for eligible couple
computations when only one member of the couple is a converted blind recipient.)
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2.
Line by Line Instructions
Line 1 – Enter the amount remaining after applying the exemptions and exclusions in SI SF01210.518.
Line 2 – Enter the $7.50 general exclusion. Any unused portion of one member can be applied
to the other member.
Line 3 – Self-explanatory.
Line 4 – Enter gross earned income.
Line 5 –If the $7.50 general exclusion has not been completely used on line 2 above, enter
the remainder.
Lines 6-10 – Self-explanatory.
Line 11 – Enter the allowable work related expenses – see SI SF01210.514D.4.
Lines 12-13 – Self-explanatory.
Line 14 – The unexpended income is that amount by which the prior month’s income exceeded
that month’s total allowable need (TAN): obtained from line 8 of the prior month’s
computation.
Line 15 – Self-explanatory.
Line 16 – Round down amounts of less than 50 cents and round up amounts of 50 cents or more
to the next higher dollar. The amount on this line is the BCI to be input as K income
or manually compared to the FCI.
Line 17 – Subtract the TAN (usually $215).
Line 18 – This may be either a positive or a negative figure. If negative, ignore the amount
for SSI purposes; the recipient would have been due this amount as his/her grant.
If positive, countable income exceeds the TAN. Carry unexpended income forward to
the next month.
FORM C
Eligible Couple - Both Converted Blind Recipients
Name________________________________ SSN:________________________
Name________________________________ SSN:________________________
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PERIOD:
Husband
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PERIOD:
Wife
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PERIOD:
Husband
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PERIOD:
Wife
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PERIOD:
Husband
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PERIOD:
Wife
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LINE 1 Gross Unearned Income
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LINE 2 Less General Exemption ($7.50)
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LINE 3 Countable Unearned Income
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LINE 4 Gross Earned Income
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LINE 5 Less Balance of General Exemption
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LINE 6 Remainder
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LINE 7 Less Earned Income Exemption ($85)
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LINE 8 Remainder (Line 5 minus Lines 6)
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LINE 9 Less ½ Remainder (½ of Line 7)
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LINE 10 Remainder
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LINE 11 Less Work Related Expenses
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LINE 12 Countable Earned Income
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LINE 13 Add Countable Unearned Income (Line 3)
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LINE 14 Add Unexpended Income from Prior Months (if any)
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LINE 15 Subtotal Lines 12-14
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LINE 16 Blind Countable Income (Round to Nearest Dollar)
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LINE 17 Subtract Total Allowable Need (TAN)
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LINE 18 Grant Amount (-) or Unexpended Income (+)
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