Applicant, Institutionalized Spouse:
Client Identification Number:
Community Spouse:
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DIVERSION OF INCOME TO COMMUNITY SPOUSE
			Monthly expense:
	$	0.00	RENT / MORTGAGE / CONDO FEES
	+	0.00	PROPERTY TAXES
	+	0.00	HOUSE INSURANCE
	+	522.00	UTILITY STANDARD eff. 10/1/07
	=	522.00	TOTAL SHELTER COSTS
	-	525.00	30% OF 150% OF POVERTY LEVEL FOR 2 (shelter allowance) eff 7/1/08
	=	-3.00	EXCESS SHELTER COSTS TO BE ADDED TO MINIMUM MMNA
	+	1,750.00	BASE MMNA:  150% OF POVERTY LEVEL FOR 2 eff. 7/1/08
	=	1,747.00	MMNA (MAXIMUM = $2,610.00 eff. 1/1/2008)
	-	531.25	COMMUNITY SPOUSE TOTAL INCOME
	$	1,215.75	DEFICIT in COMMUNITY SPOUSE INCOME - MAKEUP REQUIRED
	-	435.00	INCOMEOF INSTITUTIONALIZED SPOUSE (to be used as "community spouse allowance")
	$	780.75	MMNA TO BE MADE UP FROM ENHANCEMENT OF CSPA
			(If no enhancement permitted, this will be zero)
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COMMUNITY SPOUSE INCOME						INSTITUTIONALIZED SPOUSE INCOME
GROSS SSA	$	500.00			$	500.00
						0
GROSS PENSION	+	-			+	0.00
						0
OTHER PENSION	+	-			+	0.00
						0
INCOME FROM ASSETS*	+	31.25
						0
TOTAL	$	531.25			$	500.00
						0
					-	65.00	PNA eff. 7/1/2008
Assets on snapshot date		$	50,000.00
*Initial CSPA (1/2 @ snapshot date)			25,000.00		$	435.00	Amount available for community spouse allowance
eff 1/1/2008 may not exceed:		$104,400
income/mo @ avge int. rate*		$	31.25	/ mo.	-	1,215.75	Deficit in Community Spouse Income shown above
1.50%	LOCAL bankrate.com for city, CT, date of hearing
1.50%	LOCAL bankrate.com for city, CT, date of hearing				$	-780.75	Deficit after appyling institutionalized sp income
1.50%	LOCAL bankrate.com for city, CT, date of hearing						If result is negative:  Deficit to be met with
1.50%	(average of top 3 rates OR actual rate if higher)					$	income from additional assets =
*LOCAL bank per case of		Griswold v. Commissioner				$	624,600.00	assets needed to generate
Enhanced CSPA if enhancement required:							780.75	monthly income, applying average
								interest rate
Original CSPA		$	25,000.00				If result is positive:  no enhancement of
Plus additional assets if any:		+	624,600.00				CSPA; balance (less med. exp., insurance, etc.)
Enhanced CSPA:		$	649,600.00				will be applied income