SFN 1540, Part I, Income Received by Month 415-65-15-05

(Revised 10/00 ML #2629)

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Each month of the calendar year has a space on the form to enter and annualize each source of income received, indicate how it was verified, and enter the amount/unit monthly, weekly, etc.) received. Multiply the amount/unit times the appropriate annualizing figure as described in 415-25-05-15.

 

This annualized income is then multiplied by 73%, ONLY IF IT IS EARNED INCOME, to arrive at the annualized amount for that source of income. Once each source of income for the month has been annualized, total them and enter the result in Part II for that month.

 

Repeat this process for each month prior to the month of application backwards to July.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms.