| Applicant, Institutionalized Spouse: | ||||||||||
| Client Identification Number: | ||||||||||
| Community Spouse: | ||||||||||
| You can "format" these rows as "hide" when printing | ||||||||||
| Instructions: Compute blue cells, the rest computes itself | ||||||||||
| REMEMBER TO UPDATE FIGURES IN RED! | ||||||||||
| CELLS CONTAINING FORMULAE ARE LOCKED if using Excel - not web | ||||||||||
| YOU CAN EDIT THE REST | ||||||||||
| 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) | ||||||||||
| *************************************************************************************************************** | ||||||||||
| 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 | |||||||