Elderly or disabled household members - Click yes if either of the following apply:

Elderly – A person 60 years of age or older.

Disabled – A member of the household who meets one of the following criteria:

1. Receives SSI benefits or Social Security disability payments;
2. Is a recipient of disability related medical assistance under Medicaid.
3. Receives disability retirement benefits from a government agency because of a disability considered permanent under Social Security disability criteria.
4. Is a veteran with a service connected or non-service connected disability rated or paid by the Veteran's Administration (VA) at a 100% rate by the VA under Title 38 of the United States Code;
5. Is a veteran considered by the VA to be in need of regular aid and attendance or permanently housebound under Title 38 of the United States Code;
6. Is a surviving spouse of a veteran and considered by the VA to be in need of regular aid and attendance or permanently housebound or a surviving child of a veteran and considered by the VA to be permanently incapable of self-support under Title 38 of the United States Code;
7. Is a surviving spouse or surviving child of a veteran and considered by the VA to be entitled to compensation for a service-connected death or pension benefits for a non-service-connected death under Title 38 of the United States Code and has a disability considered permanent.
   Entitled as used in this definition refers to those veteran's surviving spouse and surviving children who are receiving the compensation or pension benefits stated or have been approved for such payments, but are not yet receiving them;
8. Receives a Railroad Retirement disability annuity and has been determined to qualify for Medicare;
9. Receives Supplemental Security Income (SSI) optional or mandatory supplementation;
10. Receives presumptive eligibility SSI payments
11. A recipient of disability-based State general assistance benefits, provided that the eligibility to receive any of these benefits is based upon disability or blindness criteria established by the state they receive the benefit from, which are at least as stringent as those used under SSI regulations.

Household size – Enter the number of members living in the household

Gross earned income - Gross monthly earned income is a household’s total, non-excluded earned income, before deductions are made. Gross monthly earned income is determined by adding the earned income of all members of the applicant household. Enter the total amount in this box.

Examples of earned income include, but are not limited to wages and salaries from employment (including employment of individuals under age 18 not attending school), self-employment and military re-enlistment bonuses.

Unearned income - Gross monthly unearned income is a household’s total, non-excluded unearned income, before deductions are made. Gross monthly unearned income is determined by totaling the unearned income of all members of the applicant household. Enter the total amount in this box.

Examples of unearned income include, but are not limited to Temporary Assistance for Needy Family payments, Social Security Income, general assistance payments, disability benefits, unemployment compensation, worker’s compensation, and child support.

loss offset – If the allowable cost of producing income is greater than the farm-self employment income, the loss may be averaged over the period it covers and deducted from other countable income. Enter the amount of the averaged loss on this line.

Medical costs for elderly/disabled household members – If the elderly or disabled indicator was set above, enter monthly medical expenses.

Dependent care costs – The cost for care of a child or other dependent when necessary for a household member to accept or continue employment.

Child support – Enter the amount of legally obligated child support payments paid monthly by a household member to a non-household member.

Rent or mortgage – Enter the rent or mortgage payment (including both first and second mortgages) for shelter occupied by the household.

Property tax and insurance – Enter monthly property tax and homeowners insurance if not included in the mortgage payment.

Utilities or SUA:

If your household incurs heating or cooling costs or is in receipt of LIHEAP (Low Income Households Energy Assistance Program) your household is eligible for the standard utility deduction of $758.00.

If your household is not eligible for the standard utility deduction but incurs two of the following: Electricity, Telephone, Water, Sewer, or Garbage, your household is eligible for the limited utility deduction of $279.00.

If your household is not eligible for the standard or the limited utility deduction and incurs one of the following: Electricity, Water, Sewer, or Garbage, your household is eligible for the Minimum Utility Allowance of $245.00.

If your household only incurs telephone costs, your household is eligible for the telephone standard of $34.00.