STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICANT TEST
CASE NAME CASE NUMBER CASE WORKER NAME DATE
●
Determine whose needs to consider in the MBSAC size and select the corresponding MBSAC amount.
● Use a best estimate of countable income from AU members (including penalized AU members), certain non-AU members and
sanctioned/excluded members.
● Deduct $90 from the gross earned income of each family member whose earnings are used on the CW 29.
● Compare the family’s total countable income to the MBSAC plus special needs to determine financial eligibility.
MONTH AND YEAR ___________
1. NUMBER OF FAMILY MEMBERS WHOSE NEEDS
ARE CONSIDERED IN MBSAC
2. CORRESPONDING MBSAC FOR
FAMILY SIZE IN #1 ABOVE $
3. RECURRING SPECIAL NEEDS +
4. TOTAL GROSS INCOME LIMIT =
5. GROSS EARNINGS COMPUTATION
a. Gross Earnings (Person 1) $
b. Disregard - 90
c. SUBTOTAL =
d. Gross Earnings (Person 2) $
e. Disregard - 90
f. SUBTOTAL =
g. Gross Earnings (Person 3) $
h. Disregard - 90
i. SUBTOTAL =
j. TOTAL (Line 5c, 5f and 5i) $
6. SOCIAL SECURITY BENEFITS +
7. V.A. BENEFITS +
8. UIB +
9. CHILD/SPOUSAL SUPPORT RECEIVED
(Less CSSD) +
10. UA CONTRIBUTION (From CW 71) +
11. UNEARNED IN-KIND (Total received) +
12. ALL DISABILITY INCOME +
13. OTHER (Specify) +
14. TOTAL COUNTABLE INCOME
(Line 5j through Line 13) =
SELF-EMPLOYMENT INCOME CALCULATION
EARNINGS FROM SELF-
EMPLOYMENT
PERSON 1
Line 5a
PERSON 2
Line 5d
Gross earnings from self
employment
$
$
Expenses
■ Actual ■ 40%
-
-
Net self-employment
income (Include in line 5
for appropriate person)
$
$
15. Is total countable income (Line 14) less than the total gross income limit
(Line 4)?
■
YES; eligible, complete CW 30.
■ NO; ineligible.
CW 29 (1/13) INTAKE FINANCIAL TEST - RECOMMENDED FORM
