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MEDICAID BUDGET WORKSHEET
ND DEPARTMENT OF HUMAN SERVICES/Medical Services
SFN 687 (01-2006)
Recipient(s) Name:
Case Number: Period Covered:
to
1. Monthly Gross Earned Income
2. Yearly Income From Self-Employment
Monthly Net Income from S/E
+ + + +
3. TOTAL EARNED INCOME
4. Less:
65 + 1/2 (aged, blind, disabled)
FICA
Medicare
Federal Withholding
State Income Tax
Mandatory Retirement/Union Dues
Work/Training Allowance
- - - -
5. Total Deductions and Disregards
6. TOTAL NET EARNED INCOME (Line 3 less Line 5)
7. Unearned Income:
SSI
Title II
Other (Specify)
+ + + +
8. TOTAL UNEARNED INCOME
9. TOTAL INCOME (Line 6 plus Line 8)
10. Less: Health Ins. Premium
Medicare
Child Care
Med Exp/Incurred Med of Inelig
$20 Disregard
Other (Specify)
- - - -
11. Total Disregards/Deductions
12. TOTAL NET MONTHLY INCOME (Line 9 Less Line 11)
- - - -
13. Less Appropriate Income
14. EXCESS INCOME
- - - -
15. Less: 75% Disregard (if applicable)
-
- - -
Amount Deemed to Another Unit
16. RECIPIENT LIABILITY
- - - -
17. Less Offset for Unpaid Medical Bills
18. RECIPIENT LIABILITY AFTER OFFSET
+ + + +
19. Plus Medical Care Payments (VA-AA, VA Medical Reimbursement)
20. RECIPIENT LIABILITY
Comments:
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