Fillable Form 4.: VOCATIONAL AND WORK HISTORY (Department of Health Care Services)

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Form 4.: VOCATIONAL AND WORK HISTORY (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health Care Services
VOCATIONAL AND WORK HISTORY
(To Be Completed By Applicant/Beneficiary)
Parent Number 1 Name: ____________________________________________________
List your employment and training history for the last two years. Begin with your current or latest job or training.
Gross
Gross
Name of Employer or
Training Program
Work or
Training
When
Employed
Amount
Monthly
Name of Employer or
Training Program
Work or
Training
When
Employed
Amount
Monthly
1.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
4.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
2.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
5.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
3.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
6.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
Parent Number 2 Name: ____________________________________________________
List your employment and training history for the last two years. Begin with your current or latest job or training.
Gross
Gross
Name of Employer or
Training Program
Work or
Training
When
Employed
Amount
Monthly
Name of Employer or
Training Program
Work or
Training
When
Employed
Amount
Monthly
1.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
4.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
2.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
5.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
3.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
6.
❒ Work
❒ Training
From
__/__/__
To
__/__/__
$
MC 210 S-W (05/07)
Page 1 of 2
State of California--Health and Human Services Agency Department of Health Care Services
MEDI-CAL U-PARENT DETERMINATION WORKSHEET
(To Be Completed By CWD Staff)
Case name: ______________________________________________ Worker number: _________________________
Case number:_____________________________________________ Date: __________________________________
1. Determination of Principal Wage Earner (PWE)
a. Application date OR date U-Parent deprivation began: ____________
b. To establish 24-month earnings period, check month on chart for each parent:
Month number 1: subtract two years from line (a): ______________
Month number 24: Month/Year immediately preceding line (a): ______________
Parent 1’s Earnings
Name
__________________
Current year ___________ Year __________ Year __________
$ Dec. $ Dec. $ Dec.
$
COU
Nov. $ Nov.
NTY
$ Nov.
$ Oct. $ Oct. $ Oct.
$ Sep. $ Sep. $ Sep.
$ Aug. $ Aug. $ Aug.
$ Jul. $ Jul. $ Jul.
$ Jun. $ Jun. $ Jun.
$ May $ May $ May
$ Apr. $ Apr. $ Apr.
$ Mar.
U
$
SE
Mar. $ Mar.
Total: $_____________
$ Feb. $ Feb. $ Feb.
$ Jan. $ Jan. $ Jan.
Parent 2’s Earnings
Current year ___________ Year __________ Year __________
$ Dec. $ Dec. $ Dec.
$ Nov. $ Nov. $ Nov.
$ Oct. $ Oct. $ Oct.
__________________
Name
$ Sep.
ON
$
LY
Sep. $ Sep.
$ Aug. $ Aug. $ Aug.
$ Jul. $ Jul. $ Jul.
$ Jun. $ Jun. $ Jun.
$ May $ May $ May
$ Apr. $ Apr. $ Apr.
$ Mar. $ Mar. $ Mar.
Total: $_____________
$ Feb. $ Feb. $ Feb.
$ Jan. $ Jan. $ Jan.
The parent earning the greater amount is the PWE: _______________________________________________________
(Name of PWE)
2. Is the PWE working 100 hours or more a month? ❒ Yes ❒ No
If “yes,” complete the Unemployed Parent Worksheet (MC 337).
Note: If the PWE is a recipient of Section 1931(b), he/she may exceed 100 hours with no earned income test.
MC 210 S-W (05/07)
Page 2 of 2
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Form 4.: VOCATIONAL AND WORK HISTORY (Department of Health Care Services)

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Completed 30 July 2020

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