Free 31759.pdf - Indiana

ASSISTANCE TO RESIDENTS IN COUNTY HOMES / ROOM AND BOARD ASSISTANCE BUDGET AND RECOMMENDATION
State Form 31759 (R2 / 5-96) / BAIS 0005B

Name of county

Name of applicant / recipient (first, middle, last)

Case number

Social Security number

Home address (number and street, city,state, ZIP code) Is the spouse an applicant / recipient of ARCH / RBA?

Name of spouse of applicant / recipient

Yes
Address of spouse of applicant / recipient (number and street, city, state, ZIP code)

No

Name of ARCH / RBA facility

ARCH / RBA facility address (number and street, city, state, ZIP code)

Name of guardian or responsible person

Guardian's address (number and street, city, state, ZIP code) HIB number Name of health insurance company Policy number

Date budget computed (Add "D" for desk review only)

RECOMMENDATION AND COUNTY DIRECTOR'S ACTION
Application date Date entered ARCH / RBA facility ARCH / RBA effective date Reason for adverse action

APPROVED ARCH / RBA AWARD $ $ $ $ DENIED EFFECTIVE DATE
ARCH / RBA liability

ARCH / RBA LIABILITY $ $ $ $

EFFECTIVE DATE

MEDICAID INFORMATION EFFECTIVE DATE APPROVED DENIED Reason for denial:_________________________ $ CONTINUED DISCONTINUED Reason for discontinuance: _____________
Legal citation

ACTION

CONTINUED DISCONTINUED SUSPENDED UNTIL ......................
Signature of caseworker

Date signed

Signature of director

Date signed

(Continued on the reverse side)

BUDGET COMPUTATION 1. Unearned Income of Applicant / Recipient (A / R) 2. Net earned income of A / R (From Table 2) 3. Deemed income of ineligible spouse (Line 6 from Table 1) 4. TOTAL (Lines 1 and 2 or 1, 2 and 3) 5. Personal Needs Allowance 6. Liability (Subtract Line 5 from Line 4) 7. Subtract ARCH / RBA rate 8. Deficit 9. Surplus 10. ARCH / RBA Award TABLE 1 - DEEMED INCOME OF INELIGIBLE SPOUSE 1. Countable income of ineligible spouse 2. Subtract personal needs allowance 3. Subtract ARCH / RBA rate 4. Surplus income of ineligible spouse 5. Subtract ineligible spouse's medical expenses 6. Deemed income to eligible spouse

$ + + $

$ -

$
TABLE 2 - DETERMINATION OF NET EARNINGS A B 1. Name(s) C

$ -

2. Gross earnings

$

$

$

3. Expenses (List as applicable)

= =

VERIFICATIONS AND COMPUTATIONS

4. Total expenses 5. Net earnings

$ $

$ $

$ $