State of California—Health and Human Services Agency
Department of Health Care Services
Medi-Cal Program
COUNTY USE ONLY
STUDENT EDUCATIONAL EXPENSES
(Supplement to the Medi-Cal Statement of Facts—MC 210)
Case Name: ___________________
______________________________
Case No.: _____________________
Worker No.:____________________
Date: _________________________
If you or any family member are in college or attending a similar educational institution, please fill in the following:
See MEM 50447 for allowable
education expenses.
A. Student’s name(s):
EXEMPT:
Name of institution(s):
Full-time Part-time Full-time Part-time Entire amount
Status of student(s):
Grad Undergrad Grad Undergrad Only expenses
B. Grants, Loans, Scholarships, Fellowships:
VERIFICATION (List):
Amount received: $ $
Source(s) of grants, loans, etc.:
How often received (monthly, quarterly, etc.)?
C. Expenses Per Term:
Is term a semester, quarter, year? $
Tuition/fees: $ $
Books, equipment, and school supplies: $ $
Child care necessary for school attendance: $
D. Transportation to School/Child Care:
Transportation costs allowed
(show computations):
Round trip miles per day:
School attended how many days per week:
Type of transportation used (own car, borrowed car, car
pool, bus, etc.):
Costs (per month):
� Amount paid by student (if not own car) $ $
� Amount paid by riders $ $
� Parking, tolls, etc. $ $
Is public transportation (bus, train, etc.) available? Yes No Yes No
� If yes, indicate cost: $ $
MC 210 S-E (05/07)
