Fillable Attachment #8 Monthly Budget Worksheet Submitted to Request (New York State)

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Attachment #8 Monthly Budget Worksheet Submitted to Request (New York State)

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1
Attachment #8
Monthly Budget Worksheet Submitted to Request an NHTD/TBI Housing Subsidy or Support
Participant Name _________________________________________________________ Date ___________________
Service Coordinator ________________________________________________ Phone _________________
INCOME (Please attach copies of all income verification documents)
SSI
SSDI
VA
Pension
Other
Other
Other
Total Income
Medicaid Spend Down
Total Income after Medicaid Spend Down
Participant Rental Share*
*1/3 of Total Income after Medicaid
Spend Down
Comments:
EXPENSES
Rent
Utility
Food
Phone
Cable
$ 0.00
$ 0.00
$ 0.00
Attachment #8
2
Laundry
Entertainment
Other
Other
Other
Total Expenses
Comments:
TOTALS
Total Income after Medicaid Spend Down
Total Expenses
Remaining Income
I
certify that the information above is true and correct as stated in the Waiver Participant Attestation.
P
articipant Signature ____________________________________________________ Date _____________________
A
s the Service Coordinator, I am responsible to report any change in participant status to the RRDC in a timely manner.
Any additional costs incurred by the TBI Housing Subsidy Program due to insufficient notification may become the
financial responsibility of the Service Coordination agency.
S
ervice Coordinator Signature ____________________________________________ Date _____________________
$ 0.00
$ 0.00
$ 0.00
$ 0.00
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Attachment 8 Monthly Budget Worksheet Submitted to Request (New York State)

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Completed 14 August 2020

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