MIME-Version: 1.0 Content-Location: file:///C:/1D38BA39/W-15233-20-09.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" APPLIED INCOME WORKSHEET

W-1523

(Rev. 4/09)
 
STATE OF CON= NECTICUT

DEPARTMENT = OF SOCIAL SERVICES

 

CONNECTICUT= HOME CARE PROGRAM FOR ELDERS

&nbs= p;

APPLIED INCOME WORKSHEET

 

 

Case Name:          &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;  

 

Client ID:        &n= bsp;            = ;            &n= bsp;            = ;                  &nbs= p;         Telephone Number:    <= /span>  &n= bsp;            = ;          <= /span>

 

FOR ACCESS AGENCY/PROVIDER USE ONLY

 

<= span style=3D'font-size:11.0pt;mso-bidi-font-size:10.0pt'>         Gross Monthly Income:     &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;      $        = ;       &n= bsp;            = ;      

 =

<= span style=3D'font-size:11.0pt;mso-bidi-font-size:10.0pt'>         Minus Personal Needs Allowance:    &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;  $        = ;        1,806.00        = ;      

 =

         Minus Medicare Part B Premium:    &n= bsp;            = ;            &n= bsp;            = ;    $        = ;             <= /span>96.40        = ;      

 

         Minus Monthly Medical Insurance Costs:      = ;            &n= bsp;            = ;   $        = ;     &n= bsp;      &nbs= p;            &= nbsp;     

 

                   &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;  

  &n= bsp;            = ;    Insurance Company Name

 

 

&n= bsp;

Applied Income:  Approximate amount –= ;

Subject to adjustment by the information below.

 

 

$        = ;     &n= bsp;      &nbs= p;            &= nbsp;     

If there= is Applied Income indicated above:=

 

Is the client respon= sible for any other medical expenses? &nbs= p;         Yes        = ;   No

&nbs= p;    

&nbs= p;     If Yes, name of medical service provider:        &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;   

     

      Address of medical s= ervice provider:         &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;         

=  

        = ;            &n= bsp;            = ;            &n= bsp;            = ;                    &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;          

=  

        = ;            &n= bsp;            = ;            &n= bsp;            = ;                    &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;          

 

      Amount of expense:        = ;            &n= bsp;            = ;            &n= bsp;            = ;            = $        = ;     &n= bsp;      &nbs= p;            &= nbsp;     

 

      Type of expense:        = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;             = ;      &n= bsp;      &nbs= p;            &= nbsp;     

      Date/frequency of expense:        = ;            &n= bsp;            = ;            &n= bsp;            = ;         = ;      &n= bsp;      &nbs= p;            &= nbsp;     

 

= Is the client respon= sible for the support of a related household member?          Yes        = ;   No=

 

      If Yes, name of household me= mber:        = ;            &n= bsp;            = ;                &n= bsp;            = ;            &n= bsp;            = ;       

        If more than one person, please provide the information

      described below for each person.  (Use the back of this form)<= span style=3D'font-size:9.0pt;mso-bidi-font-size:10.0pt'>

 

      Relationship:           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;                &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;       

 

      Gross monthly income of household member:     &nbs= p;            &= nbsp;         $        &n= bsp;            = ;            &n= bsp;

 

      Monthly s= helter costs:      = ;            &n= bsp;            = ;            &n= bsp;            = ;           $      &n= bsp;      &nbs= p;            &= nbsp;           &nbs= p;

  &n= bsp;     (rent, mo= rtgage, property taxes, insurance, condo fees etc.)

=  

 

Access Agency/

Provider Worker       <= /span>=            = ;            &n= bsp;            = ;            &n= bsp;            = ;                  Date         = =            = ;            &n= bsp;      


 

FOR ACU USE ONLY

Community Spousal Allowance Computation

 

1.  

2.

3.

4.

5.

6.

7.

8.

9.

10.<= /p>

11.<= /p>

12.<= /p>

13.<= /p>

 

 

+

+

+

+

=3D<= /p>

-

=3D<= /p>

+

=3D<= /p>

-

=3D<= /p>

=3D<= /p>

 

       $        = ;     &n= bsp;      &nbs= p;      

       $        = ;     &n= bsp;      &nbs= p;      

       $        = ;     &n= bsp;      &nbs= p;      

       $        = ;     &n= bsp;      &nbs= p;      

       $        = ;     720.00        = ;

       $        = ;     &n= bsp;      &nbs= p;      

       $        = ;     525.00        = ;

       $        = ;     &n= bsp;      &nbs= p;      

       $        = ;  1,750.00        = ;

       $        = ;     &n= bsp;      &nbs= p;      

       $        = ;     &n= bsp;      &nbs= p;      

  &nbs= p;    $        = ;     &n= bsp;      &nbs= p;      

       $           &nbs= p; &n= bsp;      &nbs= p;      

 

Ren= t or Mortgage (Spouse’s share)

Pro= perty taxes (Spouse’s share)

Pro= perty insurance (Spouse’s share)

Con= dominium fees (Spouse’s share)

Sta= ndard allowance for utilities

Tot= al shelter costs

Ded= uct Standard Shelter Allowance

Exc= ess shelter costs

Base minimum Monthly Needs Allowance

Mon= thly Needs Allowance (capped by Federal law at $2,739.00)

Spo= use’s Gross Monthly Income

Community Spousal Allowance

Com= munity Family Allowance

Final Applied Income Calculation

 

 

      

     &nb= sp; Approximate Applied Income (From other side)  &nb= sp;            =         $       &n= bsp;      &nbs= p;            &= nbsp;     

 

 

-<= /p>

 

-<= /p>

 

-<= /p>

       Other Monthly Medical Expenses (From other side)  = ;            = $       &n= bsp;      &nbs= p;            &= nbsp;     

 

       Community Spousal Allowance (From above)           &nbs= p;            &= nbsp; $       &n= bsp;      &nbs= p;            &= nbsp;     

      

       Community Family Allowa= nce (From above)     = ;            &n= bsp;           $       &n= bsp;      &nbs= p;            &= nbsp;     

 

 

 

      =    =3D      =     Final Applied Income            =             &nb= sp;            =             &nb= sp;            $       <= /b>&nbs= p;          =             &nb= sp;       

 

 

 

ACU Wo= rker  =       &n= bsp;  <= span style=3D'mso-tab-count:1'>        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;             =   &nb= sp;            =          Date       &n= bsp;  <= span style=3D'mso-tab-count:1'>        &= nbsp;          

 

Questions?  Call the Alternate Care Unit at (860) 424-5185.

= Notes: 

 <= /b>