VEHICLE DETERMINATION WORK SHEET
FOR 1931 GROUP
Case name Case number
DIRECTIONS VEHICLE NUMBER ONE VEHICLE NUMBER TWO VEHICLE NUMBER THREE
List all vehicles owned by anyone in the MFBU. Make ___________________ Make ____________________ Make_____________________
NOTE: Complete additional work sheets if more Model __________________ Model ___________________ Model ____________________
than three vehicles. Year ____________________ Year_____________________ Year _____________________
STEP ONE—Only Unlicensed Vehicles on Indian Reservation Which Do Not Require Licensing and All Licensed Vehicles. For All
Other Vehicles, Go to Step Two.
A vehicle used by or for the benefit of any person living in the home for any reason listed below is exempt.
1. On the job or for income producing purposes even if only on a seasonal basis or temporarily unemployed.
2. Long distance travel essential to individual’s employment, e.g., traveling sales, migrant farm worker moving from job to job.
3. Home (only one vehicle per household).
4. Transportation of incapacitated or disabled individual living in the home.
5. Transportation of primary fuel/water for the home.
Is vehicle exempt? Yes No Yes No Yes No
If yes, list reason and STOP.
If NO, go to Step Two.
Reason: _________________ Reason: _________________ Reason: __________________
STEP TWO—Only Vehicles Not Exempt in Step One
A. Enter estimate of Fair Market Value (FMV). FMV $________________ FMV $_________________ FMV $_________________
B. Licensed Only—If Unlicensed, Go to Step Two (C). – 4,650 – 4,650 – 4,650
___________ _________ ____________
Enter excess FMV (estimate of FMV minus $4,650).
If zero, then exempt, STOP.
If not zero, go to Step Two (C).
Excess FMV $ ___________ Excess FMV $ __________ Excess FMV $ ____________
C. All Remaining Vehicles—Enter encumbrance
(amount owed).
Amount owed $_________ Amount owed $ ________ Amount owed $ _________
D. Determine equity value (EV) of vehicle (FMV of vehicle Exempt: Yes No Exempt: Yes No Exempt: Yes No
from Step Two (A) minus encumbrance in
Step Two (C)). If $1,500 or less, then exempt. STOP.
EV $_________ EV $ ________ EV $ _________
STEP THREE—Countable Vehicle Value
A. Compare Step Two (B) and amounts listed for Check One Check One Check One
nonexempt vehicles in Step Two (D).
Excess FMV Excess FMV Excess FMV
Enter the lesser value. $ _______________ $ _______________ $ ________________
or or or
EV EV EV
$ _______________ $ _______________ $ ________________
B. Enter $1,500 in the column under the one vehicle with
the highest equity value. If excess FMV is the lesser
amount, enter zero. Enter zero in all columns where
$1,500 is not entered. – $ _______________ – $ _______________ – $ ________________
C. Subtract Step Three (B) from Step Three (A) and enter
result. If zero, then car is exempt. If not zero, then
enter amount on Property Reserve Work Sheet
(MC 176 P (Back) 1931). – $ _______________ – $ _______________ – $ ________________
State of California—Health and Human Services Agency Department of Health Care Services
MC 176 P-V (05/07) 1931 Group
