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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.