Date

Initialed

Patient Identification Number

PATIENT’S NAME

Last

First

Middle Initial

In questions 1 through 4 below, please circle one number or group of numbers:

1.

NUMBER OF PERSONS IN FAMILY

1

2

3

4

5

6 or more

2.

NUMBER OF CHILDREN

1

2

3

4

5 or more

3.

AGE OF OLDEST CHILD IN YEARS

0-5

6-15

16-17

18 and over

4.

AGE OF HEAD OF HOUSEHOLD

Under 35

35-54

55-64

65 and over

BUREAU OF LABOR STATISTICS (BLS) EQUIVALENCE FACTOR=

(see Table B)

A.

LOCATION

(See Table C, List of Metropolitan Counties by SMSA Definition)

BLS METRO

=

$12,815

BLS NON-METRO

=

$11,604

B.

STANDARD BUDGET

BLS EQUIVALENCE

BLS STANDARD

FAMILY STANDARD

FACTOR

BUDGET

BUDGET

$

X

$

=

$

(metro or non-metro)

C.

PARTICIPATION DETERMINATION

ADJUSTED GROSS

FAMILY STANDARD

INCOME

BUDGET

$

 -

$

=

$

X

.333

=

$

D.

ADJUSTED GROSS INCOME

$

X

.125

=

$

LESSER OF C or D

=

$

E.

ADJUSTED GROSS INCOME

=

$

FAMILY STANDARD BUDGET

=

$

(B. above)

F.

FEDERAL INCOME TAX

STATE INCOME TAX

TOTAL TAX

$

+

$

=

$

TOTAL TAX

BLS STANDARD TAX

$

-

$

=

$

(metro $1,435)

(non-metro $1,260)

G.

SPECIAL CARE FOR CHILDREN

$

H.

SCHOOL TUITION

$

I.

FAMILY SUPPORT PAID

$

J.

OTHER PAYMENTS

1.

Transportation to and from dialysis

$

2.

Employment Expense (dues, uniforms, small tools)

$

SOCIAL SECURITY

BSL STANDARDS

$

-

$

=

$

(metro $702)

(non-metro $676)

K.

MEDICAL EXPENSES

BLS STANDARD

MEDICAL EXPENSES

ALLOWED

$

-

$

=

$

(includes medical

(metro $876)

insurance premiums)

(non-metro $671)

MEDICAL EXPENSES

TOTAL EXPENSES

INCOME IN EXCESS

ALLOWED

$

-

$

=

$

(E through K totaled, less

adjusted gross income)

L.

INCOME IN EXCESS

$

X     .333

=

$

M.

ENTER SMALLEST AMOUNT OF C or D or L

$