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Household Income Determination Worksheet

Attachment "B"

Print out this worksheet, and list the name of each member of the household with an income, and provide the amounts (including total household income).

Enter the amount of income for all wage earners in the household:

Name:	__________	__________	__________	__________	__________
Alimony	$	$__________	$__________	$__________	$__________
Allowance	$__________	$__________	$__________	$__________	$__________
Insurance Annuity	$__________	$__________	$__________	$__________	$__________
Pension	$__________	$__________	$__________	$__________	$__________
Public Assistance	$__________	$__________	$__________	$__________	$__________
Self-Employed Wages	$__________	$__________	$__________	$__________	$__________
Social Security	$__________	$__________	$__________	$__________	$__________
Spouse Wages	$__________	$__________	$__________	$__________	$__________
Unemployment	$__________	$__________	$__________	$__________	$__________
Wages	$__________	$__________	$__________	$__________	$__________
Other	$__________	$__________	$__________	$__________	$__________
Total:	$__________	$__________	$__________	$__________	$__________

Total of all Wage Earners: $___________________

Maximum Income(200% FPL) by Household Size

Household Size	Max. Income
1	$1806
2	$2428
3	$3052
4	$3675
5	$4298
6	$4922
7	$5545
8	$6168
9	$6791

Add $623.00 for each household member if household size is over 9.

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