Click for Poverty Guidelines ( RCP Must Use 200% Poverty Rate)

Tennessee Department of Children’s Services RELATIVE CAREGIVER PROGRAM DETERMINATION OF FINANCIAL ELIGIBILITY

Household Income Declaration

Caregiver’s Name Date

TYPE OF INCOME TREATMENT OF INCOME FOR RELATIVE MEMBER OF MONTHLY CAREGIVER PROGRAM HOUSEHOLD AMOUNT Income Producing Trust COUNT Interest Payments, COUNT Dividends, Annuities, Royalties and Interest Pension COUNT Military Allotments COUNT: Eligible Children DO NOT COUNT: Adults Unemployment COUNT Compensation Rental Income COUNT Self-Employment COUNT as earned income minus the cost of Enterprises doing business. Examples include roomers, boarders, beauticians, Tupperware sales, etc. Severance Pay COUNT unless paid as one lump sum Social Security Benefits COUNT: Eligible Children DO NOT COUNT: Adults SSI Payments COUNT: Eligible Children DO NOT COUNT: Adults Wages, Salaries, COUNT Commissions Veteran’s Benefits COUNT Families First COUNT Other Source of Monthly COUNT Income TOTAL ANNUAL HOUSEHOLD INCOME

DETERMINED BY (choose one) ACCENT DATABASE DOCUMENT REVIEW

Size of Family Unit Click for Poverty Guidelines ( RCP must use 200% poverty rate)

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. Distribution: Relative Caregiver Case File CS-0614 (rev 10/09) Page 1 Countable Resource Declaration

RESOURCE TYPE RELATIVE CAREGIVER PROGRAM MEMBER OF MONTHLY HOUSEHOLD AMOUNT Bonds COUNT Cash On Hand COUNT Checking Accounts COUNT Non-Recurring Lump Sum COUNT: Windfall, Cash Prize, Awards, Income Payments Tax Refunds Property – Buildings, Land, COUNT: Equity Value of Boat, Vacation Homes Real Estate and and Mobile Homes that are not Homestead Recreational Properties DO NOT COUNT if household is making a good faith effort to sell for nine months Savings Accounts COUNT Savings Certificate Stocks COUNT if not part of a retirement plan Trust Funds Exempt if (1) Trust established by will (2) Trust is producing income (3) Trust set up for a minor and is $5,000 or less Other COUNT TOTAL ANNUAL COUNTABLE RESOURCES

Countable Resource Limit is $15,000.00

DETERMINED BY (choose one) ACCENT DATABASE DOCUMENT REVIEW

SIZE OF FAMILY UNIT

CAREGIVER IS FINANCIALLY ELIGIBLE FOR SERVICES Yes No

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. Distribution: Relative Caregiver Case File CS-0614 (rev 10/09) Page 2