Client Explanation

Benefits Paid

Household Information

Income Information

Reported Gross Self-Employment Income -

Unreported Gross Self-Employment Income -

Expenses

Utilities(FUA, LUA, TUA, or IUA)

Yes (STD prior to 10-1-2002)
Yes
Yes (Effective 10-1-2004)
Yes (Effective 10-1-2006)
0.00 if no FUA/LUA.
Prior to 10-1-08 max age 2 or under = $200 - all others $175
Aged/Disabled Medical Expense:

Adjustments

(Including aged off benefits)

Comments

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