SFN 530, Part II, Income Deductions 415-65-10-10

(Revised 10/00 ML #2629)

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In Section A, enter the name of the medical vendor and the verified annual amount of the medical bill or cost for each medical expense allowed. Indicate how each was verified (statement from vendor, viewed bill, cancelled check, receipt, et cetera).

 

Enter the total of all verified allowable medical expenses on line 1.

 

In section B, enter the amount of any verified, paid alimony or child support. If it is documented that the alimony/support is being paid on a regular basis, it may be annualized and the applicant given a full year's deduction even though the entire amount has not actually been paid yet. Enter annualized total on line 2.

 

Enter the annualized amount of child care deduction in section C, line 3.

 

Enter any other deductions (415-25-05-05) in Section D and total on line 4.

 

Combine all deductions on line E.

 

NOTE: The annual deductions must be deducted from the annual gross income each time the benefit level is recomputed due to a change in the income status.

 

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