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Effective Date: 
4/2020

Documents

 

Instructions

Updated: 7/2016

 

Detailed Instructions

Co-payment Due Fill in the review period.

Individual’s Gross Monthly Work Income No action required. (This field autopopulates by adding the entries for employee wages/salary and commission/tips/etc.)

Employee wages or salary — Enter the individual’s monthly wages or salary.

Commission, tips, piece-rate payments, cash bonuses — Enter the individual’s monthly commissions, tips, etc.

Individual’s Net Monthly Receipts – Non-Farm — No action required. (This field autopopulates by subtracting the total business expenses from the gross receipts.)

Gross Receipts — Enter the individual’s total receipts for non-farm goods and services.

Business Expenses — Enter the individual’s non-farm business expenses on the lines provided.

Total Business Expenses — No action required. (This field autopopulates by adding the non-farm business expense entries.)

Individual’s Net Monthly Receipts/Farm Self-employment — No action required. (This field autopopulates by subtracting the total business expenses from the total gross receipts.)

Gross Receipts Enter the individual’s total receipts for farm goods and services on the lines provided.

Total Gross Receipts — No action required. (This field autopopulates by adding the entries for farm goods and services.)

Business Expenses — Enter the individual’s farm business expenses on the lines provided.

Total Business Expenses — No action required. (This field autopopulates by adding the farm business expense entries.)

Individual’s Benefits — Enter the individual’s benefits on the lines provided.

Total Benefits — No action required. (This field autopopulates by adding the benefit entries.)

Individual’s Other Income — Enter any other income the individual gets on the lines provided. Average receipts over a 12-month period.

Total Other Income — No action required. (This field autopopulates by adding the other income entries.)

Spouse’s Gross Monthly Work Income No action required. (This field autopopulates by adding the entries for employee wages/salary and commission/tips/etc.)

Employee wages or salary — Enter the spouse’s monthly wages or salary.

Commission, tips, piece-rate payments, cash bonuses — Enter the spouse’s monthly commissions, tips, etc.

Spouse’s Net Monthly Receipts/Non-Farm — No action required. (This field autopopulates by subtracting the total business expenses from the gross receipts.)

Gross Receipts — Enter the spouse’s total receipts for non-farm goods and services.

Business Expenses — Enter the spouse’s non-farm business expenses on the lines provided.

Total Business Expenses — No action required. (This field autopopulates by adding the non-farm business expense entries.)

Spouse’s Net Monthly Receipts/Farm Self-employment — No action required. (This field autopopulates by subtracting the total business expenses from the total gross receipts.)

Gross Receipts Enter the spouse’s total receipts for farm goods and services on the lines provided.

Total Gross Receipts — No action required. (This field autopopulates by adding the entries for farm goods and services.)

Business Expenses — Enter the spouse’s farm business expenses on the lines provided.

Total Business Expenses — No action required. (This field autopopulates by adding the farm business expense entries.)

Spouse’s Benefits — Enter the spouse’s benefits on the lines provided.

Total Benefits — No action required. (This field autopopulates by adding the benefit entries.)

Spouse’s Other Income — Enter any other income the spouse gets on the lines provided. Average receipts over a 12-month period.

Total Other Income — No action required. (This field autopopulates by adding the other income entries.)

Individual Monthly Income — No action required. (This field autopopulates by adding the individual’s gross monthly work income, net monthly receipts/non-farm, net monthly receipts/farm self-employment, total benefits and total other income.)

Spouse Monthly Income — No action required. (This field autopopulates by adding the spouse’s gross monthly work income, net monthly receipts/non-farm, net monthly receipts/farm self-employment, total benefits and total other income.)

Total Monthly Income — No action required. (This field autopopulates by adding the individual’s monthly income and the spouse’s monthly income.)

Additional Exclusions — Refer to Texas Administrative Code (TAC), Title 40, Part 1, Chapter 44, §44.501(i)(1)-(8) to determine if the individual or spouse can claim other exclusions. Describe the exclusions on the lines provided and enter the amounts.

Total Exclusions — No action required. (This field autopopulates by adding the exclusion entries.)

Additional Deductions — Refer to 40 TAC §44.501(j)(1)-(10) to determine if the individual or spouse can claim other deductions. Describe the deductions on the lines provided and enter the amounts. 

Total Deductions — No action required. (This field autopopulates by adding the deduction entries.)

Total Exclusions and Deductions — No action required. (This field autopopulates by adding the total exclusions and total deductions.)

Net Monthly Income — No action required. (This field autopopulates by subtracting the total exclusions and deductions from the total monthly income.)

Co-pay Percentage — No action required. (This field autopopulates with the percentage from the Co-pay Percentage Schedule that corresponds to the net monthly income.)

Weekly Units  — Refer to Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and enter the weekly units of service.

Multiplied by 4.33 — No action required. (This field autopopulates by multiplying the weekly units by 4.33, which equals the monthly units of service.)

Monthly Units of Service — This field automatically rounds the monthly units of service to the nearest quarter-hour. Refer to the Rounding of Time Increments table, if necessary.

Unit Rate — Enter the unit rate from the contract agreement.

Total Cost for the Month — No action required. (This field autopopulates by multiplying the monthly units of service by the unit rate.)

Monthly Co-payment — No action required. (This field autopopulates by multiplying the total cost for the month by the co-pay percentage.)

Co-payment Questions/Reduction or Waiver of Co-payment Questions/Block Grant Option Questions/Questions for All Payment Models — Answer Yes/Met, No/Not Met or N/A for each question. Enter notes where applicable.