Financial Inventory for Assessment of Economic Need

Client’s name: ______________________________________ Counselor: ________________________________

A. On last year’s Federal Income Tax form which included you, how many dependents were claimed? _______

B. Please list your income in the following areas. If you don’t have income in an area, please enter $0. You do not have to list SSI, Welfare benefits, food stamps, or other forms of public assistance.

1. Your wages (gross) ____________ per month OR ____________ per year

2. Your spouse’s wages (gross) ____________ per month OR ____________ per year

3. Farm or business income (net) ____________ per month OR ____________ per year

4. Pension or Retirement benefits ____________ per month OR ____________ per year

5. Worker’s Compensation ____________ per month OR ____________ per year

6. Insurance benefits (including SSDI) ____________ per month OR ____________ per year

7. Interest or Dividends ____________ per month OR ____________ per year

8. Child support received ____________ per month OR ____________ per year

9. All other sources ____________ per month OR ____________ per year

w w w w w w w

C . To Be Completed by Counselor:

1. Total Annual Income _____________________ per year

(Add all entries in Part B. Multiply by 12 if listed monthly to get annual figure.)

2. Subtract Income Exclusion _____________________

(Use number of dependents on Line A with Chart A on back.)

3. Equals Applicable Income (Line 1 minus Line 2) _____________________

4. Required Client Participation (Use Chart B)

a. ______% of _______________________ which equals __________________________

(Annual Service Costs)

b. ______% of _______________________ which equals __________________________

(Applicable Income) (Annual Maximum)

D. Client Participation:

    1. The Smaller of 4a or b, Above _______________________________
    2. Other Client/Family Participation MINUS _______________________________
    3. Maximum Client Participation EQUALS _______________________________

I hereby certify that the above is an accurate representation of my income and dependents, and I will provide documentation to support the above information if requested to do so. I agree to notify my DVRS counselor if my financial condition changes materially.

 

 

(Signature) ________________________________________________ (Date) _________________________

 

 

 

(Side A)

I. Item/Service(s) to be purchased Cost

1. ___________________________________________________ _________________________

2. ___________________________________________________ _________________________

3. ___________________________________________________ _________________________

4. ___________________________________________________ _________________________

Total Cost......

 

II. Comparable Services and Benefits [Other agencies or sources of funding for above item/service(s)]

AGENCY/SOURCE AMOUNT

1. ___________________________________________________ _________________________

2. ___________________________________________________ _________________________

3. ___________________________________________________ _________________________

4. ___________________________________________________ _________________________

Total Assistance from others.......

III. ANNUAL SERVICE COSTS (I. Costs minus II. Benefits).......

Chart A

Exclusion Table

Family Size Income Exclusion Allowance

1 10,756

2 14,497

3 18,238

4 21,979

For each additional person add +3,741 = __________________

Chart B

Participation Table

Applicable Income % Participation Annual Maximum

100 - 1,999 10.0% of costs up to 5.0% of applicable income

2,000 - 3,999 15.0% " 7.5% "

4,000 - 5,999 20.0% " 10.0% "

6,000 - 8,499 25.0% " 12.5% "

8,500 - 10,999 30.0% " 15.0% "

11,000 - 13,999 35.0% " 17.5% "

14,000 - 16,999 40.0% " 20.0% "

17,000 - 19,999 50.0% " 20.0% "

20,000 - 24,999 60.0% " 25.0% "

25,000 - 29,999 70.0% " 25.0% "

30,000 and higher 80.0% " 25.0% "

(Side B)

R-406 (Rev. 5/99)

283-1157