Worksheet a Household Income/ Respite Allocation
Completed for all consumers at case opening, annually thereafter, or if financial status change occurs.
Consumer Name / ID Number
SECTION 1: PAYEE INFORMATION (to be entered in Private Pay Eligibility screen of CMHC, beginning at Field #20)
First Name / Middle Init / Last Name
Street Address / Apt# / City / State / Zip Code
Telephone Number (Area Code and Number) / Relationship To Consumer
SECTION 2: ABILITY TO PAY CALCULATION USING STATE INCOME TAX RETURN (preferred method)
A. / Total Household Income – Gross Income from Michigan Income Tax Return (enter in Field 6 of Private Pay Eligibility Screen). Fill in sources of income below. / A.
B. / Taxable (Adjusted) Income from Michigan Income Tax Return (read note in column 3 below before recording this amount). Enter the number of dependents in E. below. / B.
C. / Ability to Pay from ATP schedule on back of worksheet based on income listed on line B. above. / C.
SECTION 3: ABILITY TO PAY CALCULATION USING TOTAL GROSS EARNED INCOME FROM LINE 4t, (below)
**This method to be used only when Michigan Income Tax Return is not available.**
1—ANNUAL HOUSEHOLD INCOME / 2—ANNUAL AMOUNT / 3 / 4—GROSS EARNED INCOME
1a. Compensation from employment / 2a. / NOTE: Carry each
taxable amount listed in Column 2 “AMOUNT”
over to Column 4-“ATP Income” for use in computing monthly liability. If spouse is not biological or adoptive parent of a Dependent Child Consumer, do not carry spouse’s income (2b. 2d., 2f. over to Column 4 as it is not to
be for purposes of determining monthly liability in this Instance. / 4a.
1b. Compensation from employment (spouse) / 2b. / 4b.
1c. Unemployment compensation / 2c. / 4c.
1d. Unemployment compensation (spouse) / 2d. / 4d.
1e. Workmen’s compensation / 2e. / 4e. / N/A
1f. Workmen’s compensation (spouse) / 2f. / 4f. / N/A
1g. Social Security Benefits / 2g. / 4g. / N/A
1h. Social Security Benefits (spouse) / 2h. / 4h. / N/A
1i. Indian Tribal Income / 2i. / 4i. / N/A
1j. Indian Tribal Income (spouse) / 2j. / 4j. / N/A
1k. Veterans Benefits / 2k. / 4k. / N/A
1l. Veterans Benefits (spouse) / 2l. / 4l. / N/A
1m. *Retirement Plans – ONLY if retired / 2m. / 4m.
1n. *Retirement Plans – ONLY if retired (spouse) / 2n. / 4n.
1o. Alimony / 2o. / 4o.
1p. Child Support / 2p. / 4p. / N/A
1q. Adoption Subsidy / 2q. / 4q. / N/A
1r. Other (DHS Assistance, including Bridge Card)
Describe: / 2r. / 4r. / N/A
1s. Interest Income, Rental Income, etc. / 2s. / 4s.
Total Household Income
(Field #6 Private Pay Eligibility) / 2t. / Total Gross Earned Income
(before exemptions) / 4t.
*Retirement & pension benefits may be taxable or non-taxable based on individual’s compensation plan. Consumers must provide documentation to verify type of plan.
SECTION 4: ABILITY TO PAY CALCULATION
D. Total Annual ATP Income (from 4t above) / D.
E. Number of exemptions claimed on State Income Tax ______x $3600.00 (Field 4 Private Pay Eligibility) / E.
F. ATP Adjusted Income [Line D minus E. If zero or less than zero, enter -0- on Line F.] (Field 7 Private Pay Eligibility) / F.
G. Ability To Pay from ATP schedule on back of worksheet, based on income listed on Line F. above / G.
SECTION 5: RESPITE ALLOCATION AMOUNT (from table on back of Worksheet)
Respite Consumer
Respite Only Consumer
Non-Respite Consumer / Using State Taxable Income (Section 2, Box B or Section 4, Box F)
Select appropriate allocation from Respite Allocation Schedule on back of form / $
VERIFICATION OF INCOME
Copies of documents verifying income amounts listed above are to be attached to completed worksheet. If worksheet is completed
off-site (away from CMHCM clinic) and copies cannot be obtained, CMHCM staff completing worksheet must sign below to verify
that he/she has viewed documentation which supports accuracy of income information presented on this worksheet.
CMHCM STAFF SIGNATURE REQUIRED______DATE______
CMHCM-801 [White] (Revised-3/26/09)
FINANCIAL LIABILITY SCALE FOR CLINICAL SERVICES
STATE TAXABLE(ADJUSTED) INCOME / ABILITY-TO-PAY
MONTHLY / STATE TAXABLE
(ADJUSTED) INCOME / ABILITY-TO-PAY
MONTHLY
$ 10,000 TO $ 11,000 / $11 / $ 30,001 TO $ 31,000 / $225
$ 11,001 TO $ 12,000 / $ 14 / $ 31,001 TO $ 32,000 / $244
$ 12,001 TO $ 13,000 / $ 18 / $ 32,001 TO $ 33,000 / $ 264
$ 13,001 TO $ 14,000 / $ 22 / $ 33,001 TO $ 34,000 / $ 284
$ 14,001 TO $ 15,000 / $ 27 / $ 34,001 TO $ 35,000 / $ 304
$ 15,001 TO $ 16,000 / $ 32 / $ 35,001 TO $ 36,000 / $ 324
$ 16,001 TO $ 17,000 / $ 38 / $ 36,001 TO $ 37,000 / $ 344
$ 17,001 TO $ 18,000 / $ 45 / $ 37,001 TO $ 38,000 / $ 364
$ 18, 001 TO $ 19,000 / $ 53 / $ 38,001 TO $ 39,000 / $ 384
$ 19,001 TO $ 20,000 / $ 62 / $ 39,001 TO $ 40,000 / $ 405
$ 20,001 TO $ 21,000 / $ 72 / $ 40,001 TO $ 41,000 / $ 426
$ 21,001 TO $ 22,000 / $ 83 / $ 41,001 TO $ 42,000 / $ 447
$ 22,001 TO $ 23,000 / $ 95 / $ 42,001 TO $ 43,000 / $ 468
$ 23,001 TO $ 24,000 / $ 108 / $ 43,001 TO $ 44,000 / $ 489
$ 24,001 TO $ 25,000 / $ 122 / $ 44,001 TO $ 45,000 / $ 510
$ 25,001 TO $ 26,000 / $ 137 / $ 45,001 TO $ 46,000 / $ 531
$ 26,001 TO $ 27,000 / $ 153 / $ 46,001 TO $ 47,000 / $ 552
$ 27,001 TO $ 28,000 / $ 170 / $ 47,001 TO $ 48,000 / $ 573
$ 28,001 TO $ 29,000 / $ 188 / $ 48,001 TO $ 49,000 / $ 594
$ 29,001 TO $ 30,000 / $ 206 / $ 49,001 TO $ 50,000 / $ 615
FOR STATE TAXABLE INCOME OVER $50,000
ABILITY TO PAY SHALL BE .15 OF THAT INCOME
RESPITE ALLOCATIONS BASED ON INCOME AND MEDICAID ELIGIBILITY
Suggested MaximumSTATE TAXABLE (ADJUSTED) INCOME / ANNUAL RESPITE ALLOCATION
$12,500 … or Medicaid Eligibility / $1000
$12,501 TO $15,000 / $990
$15,001 TO $20,000 / $980
$20,001 TO $23,000 / $970
$23,001 TO $27,000 / $960
$27,001 TO $30,000 / $950
$30,001 TO $35,000 / $940
$35,001 TO $45,000 / $930
$45,001 TO $55,000 / $920
$55,001 TO $65,000 / $910
$65,001 TO $75,000 / $900
$75,001 TO $85,000 / $880
$85,001 TO $100,000 / $860
Annual Respite Allocation may be increased regardless of the consumer/family’s income
Based on Medical Necessity of the consumer and documented in the Person Centered Plan
Supervisor’s signature is required. Program Director’s signature is required if over $1,000.
Supervisor’s Signature:______Amount:______Date:______
Program Director’s Signature:______Amount:______Date:______