Form MC280 TB "Tuberculosis (Tb) Program Financial Eligibility Work Sheet - Eligible Child With Ineligible Parent or Parent(S)" - California

What Is Form MC280 TB?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2007;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form MC280 TB by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form MC280 TB "Tuberculosis (Tb) Program Financial Eligibility Work Sheet - Eligible Child With Ineligible Parent or Parent(S)" - California

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Department of Health Care Services
State of California—Health and Human Services Agency
TUBERCULOSIS (TB) PROGRAM
FINANCIAL ELIGIBILITY WORK SHEET—ELIGIBLE CHILD
WITH INELIGIBLE PARENT OR PARENT(S)
CASE NAME
CASE NUMBER
APPLICANT’S NAME
PART I. INELIGIBLE PARENT’S UNEARNED INCOME
1. Parent’s unearned income—do not include public assistance (PA), other PA, or TB parent’s income.
Do not include parent’s income if spouse is PA, other PA, or TB:
$ ____________
2. Allocation for ineligible children (if no children, enter zero in Part I.2.c.). Do not include TB applicant or
TB-eligible children.
#1
#2
#3
#4
CHILD
CHILD
CHILD
CHILD
Name
Name
Name
Name
a. Standard SSI allocation (Federal
Benefit Rate [FBR] for a couple minus
FBR for an individual):
b. Minus child’s income:
c. Total allocation:
________
+ _______
+ _______
+ _______ = $ ____________
3. Remaining unearned income (subtract line I.2.c. from line I.1.):
$ ____________
PART II. INELIGIBLE PARENT’S EARNED INCOME
1. Parent’s gross earned income: ............................................................................................................. $ ____________
2. Unused portion of allocation for ineligible child(ren): ............................................................................ $ ____________
3. Remaining earned income (subtract II.2. from II.1.):............................................................................. $ ____________
IF THERE IS NO INCOME REMAINING AND I.3 AND II.3. ARE BOTH ZERO, DO NOT DEEM, GO TO PART IV.
IF THERE IS INCOME, PROCEED WITH PART III.
PART III. COMBINED INCOMES—Ineligible Parents
PART IV. TB ELIGIBILITY CALCULATION
Unearned Income
1. Deemed income from Part III.15.
1. Remaining unearned income (after allocation) or zero (from I.3.)
2. Eligible child’s own OASDI income
2. A. Subtract general income exclusion
–20
3. Other unearned income
B. Subtract other unearned income deductions
4. A. Subtract general income exclusion
–20
3. Countable unearned income (to III.11.)
B. Subtract other unearned income deductions
Earned Income
5. Countable unearned income (IV.1. + IV.2. + IV.3. – $20)
4. Remaining earned income (from II.3.)
6. A. Child’s countable earned income
(subtract $65 +
/
remainder)
1
2
5. Subtract balance of general income exclusion
6. Remainder
B. Subtract other earned income deductions
7. A. Subtract work expense exclusion
–65
7. Total countable income
B. Subtract other earned income deductions
8. Current TB income standard
8. Remainder
If line IV-7 is less than or equal to line IV.8., this person is income eligible.
9. Subtract
1
/
remainder
2
10. Countable earned income (to III.12.)
Deemed Income
11. Countable unearned income (from III.3.)
12. Add countable earned income (from III.10.)
13. Total countable income (from III.11. + III.12.)
14. Subtract parent deduction*
15. Deemed income. Enter on Line IV.1.
* Individual FBR if one ineligible parent lives with child; couple FBR if both ineligible parents live with child.
MC 280 TB (05/07)
Department of Health Care Services
State of California—Health and Human Services Agency
TUBERCULOSIS (TB) PROGRAM
FINANCIAL ELIGIBILITY WORK SHEET—ELIGIBLE CHILD
WITH INELIGIBLE PARENT OR PARENT(S)
CASE NAME
CASE NUMBER
APPLICANT’S NAME
PART I. INELIGIBLE PARENT’S UNEARNED INCOME
1. Parent’s unearned income—do not include public assistance (PA), other PA, or TB parent’s income.
Do not include parent’s income if spouse is PA, other PA, or TB:
$ ____________
2. Allocation for ineligible children (if no children, enter zero in Part I.2.c.). Do not include TB applicant or
TB-eligible children.
#1
#2
#3
#4
CHILD
CHILD
CHILD
CHILD
Name
Name
Name
Name
a. Standard SSI allocation (Federal
Benefit Rate [FBR] for a couple minus
FBR for an individual):
b. Minus child’s income:
c. Total allocation:
________
+ _______
+ _______
+ _______ = $ ____________
3. Remaining unearned income (subtract line I.2.c. from line I.1.):
$ ____________
PART II. INELIGIBLE PARENT’S EARNED INCOME
1. Parent’s gross earned income: ............................................................................................................. $ ____________
2. Unused portion of allocation for ineligible child(ren): ............................................................................ $ ____________
3. Remaining earned income (subtract II.2. from II.1.):............................................................................. $ ____________
IF THERE IS NO INCOME REMAINING AND I.3 AND II.3. ARE BOTH ZERO, DO NOT DEEM, GO TO PART IV.
IF THERE IS INCOME, PROCEED WITH PART III.
PART III. COMBINED INCOMES—Ineligible Parents
PART IV. TB ELIGIBILITY CALCULATION
Unearned Income
1. Deemed income from Part III.15.
1. Remaining unearned income (after allocation) or zero (from I.3.)
2. Eligible child’s own OASDI income
2. A. Subtract general income exclusion
–20
3. Other unearned income
B. Subtract other unearned income deductions
4. A. Subtract general income exclusion
–20
3. Countable unearned income (to III.11.)
B. Subtract other unearned income deductions
Earned Income
5. Countable unearned income (IV.1. + IV.2. + IV.3. – $20)
4. Remaining earned income (from II.3.)
6. A. Child’s countable earned income
(subtract $65 +
/
remainder)
1
2
5. Subtract balance of general income exclusion
6. Remainder
B. Subtract other earned income deductions
7. A. Subtract work expense exclusion
–65
7. Total countable income
B. Subtract other earned income deductions
8. Current TB income standard
8. Remainder
If line IV-7 is less than or equal to line IV.8., this person is income eligible.
9. Subtract
1
/
remainder
2
10. Countable earned income (to III.12.)
Deemed Income
11. Countable unearned income (from III.3.)
12. Add countable earned income (from III.10.)
13. Total countable income (from III.11. + III.12.)
14. Subtract parent deduction*
15. Deemed income. Enter on Line IV.1.
* Individual FBR if one ineligible parent lives with child; couple FBR if both ineligible parents live with child.
MC 280 TB (05/07)
INSTRUCTIONS
FINANCIAL ELIGIBILITY WORK SHEET FOR MC 280 TB (TB CHILD)
There is no deeming from any parent if one or both parents is public assistance (PA), other PA, or eligible for the TB program.
PART I.
INELIGIBLE PARENT’S UNEARNED INCOME
Line
I.1.
Enter the ineligible parent’s unearned income.
Line
I.2.
(If no ineligible siblings, enter zero in I.2.c.) Enter the first name of any ineligible child(ren) in the
box provided. On line 2.a., enter the allocations for any ineligible child(ren) not on PA or not applying
for or eligible for the TB program. On line 2.b., enter any income for each of the children, excluding
up to $400 per month but no more than $1,620 per year if student income. Subtract line 2.b. from
2.a., enter the remainder for each child and total the allocations for all siblings on line 2.c.
Line
I.3.
Subtract line I.2.c. from line I.1. (unearned income) and enter the difference. This is the remaining
unearned income amount unless the allocation amount (line I.2.c.) exceeds line I.1. (unearned
income). In the latter case, the negative figure on line I.3. is carried over to line II.2. (unused portion
of allocation).
PART II.
INELIGIBLE PARENT’S EARNED INCOME
Line II.1.
Enter the parent’s earned income.
Line II.2.
Enter the amount of any allocation for ineligible children that is not offset by unearned income
(line I.2.c. minus line I.1.). If line I.1. is greater than line I.2.c., enter zero in line II.2.
Line II.3.
Subtract the allocation amount on line II.2. from line II.1. (gross earned income) and enter the
difference.
NOTE: If, at this point (after the allocation for ineligible children), there is no income remaining either earned or
unearned, there is no income available for deeming to the eligible child(ren). In this case, enter zero on line III.15.
and proceed to Part IV. If there is earned and/or unearned income remaining, complete both Parts III and IV.
PART III.
COMBINED INCOMES
Enter any remaining unearned income from line 1.3. on line III.1. and any remaining earned income from line II.3.
on line III.4. Follow the instructions on each line.
The entry on the last line of Part III (i.e., the “Deemed Income” line) is carried over to the first line (also titled
“Deemed Income”) on Part IV, “TB Eligibility Calculation.”
PART IV.
TB ELIGIBILITY CALCULATION
Line IV.1.
Enter the deemed income from the last line in Part III. The deemed income is treated as unearned
income.
Line IV.2.
Enter the applicant’s OASDI income.
Line IV.3.
Enter any other unearned income of applicant.
Line IV.4.
A. Enter the $20 any income exclusion.
Line IV.4.
B. Subtract any other unearned income deductions.
Line IV.5.
Add together the amounts in lines IV.1., IV.2., and IV.3., and then subtract the $20 any income
exclusion (line IV.4.) to obtain the total countable unearned income amount.
Line IV.6.
A. Enter the applicant’s countable earned income (i.e., earned income after exclusions including the
$65 expense exclusion and 1/2 the remainder.
Line IV.6.
B. Subtract other earned income deductions.
Line IV.7.
Add the amounts in lines IV.5. and IV.6. to obtain the total countable income.
Line IV.8.
Enter the current TB income standard.
If line IV.7. is less than or equal to line IV.8., the child applicant is income eligible.
MC 280 TB (05/07)
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