Benefit’s Analysis Participant’s Name:____________________________Date:______________________________ Age:__________________ DOB:______________________________ Monthly Income Unearned Income: SSI: $_____________ Claims Rep Name:____________________ W/C: $_____________ SSDI: $_____________ Claims Rep Name:____________________ Financial Aide$_____________ UI: $_____________ TANF: $_____________ VA: $_____________ Food Stamps: $_____________ RR: $_____________ State Subsidized Alimony:$_____________ Housing: $_____________ Child Support:$_____________ HUD:$_____________ Other:$_____________ Private Disability Insurance: $_____________ Earned Income: Employer Name:_________________________________ Supervisor:______________________________________ Address:________________________________________ Phone Number:__________________________________ Start Date:______________________________________ Hourly Pay: $_____________ Hours per week:______________ Gross Monthly Amount: $_____________ Gross Weekly Amount: $_____________ Gross Bi-weekly Amount:$_____________ Other Income in Household (If applies) Spouse: Name:___________________________________ Gross Monthly Amount: $______________ Parents: (List the person only that brings income into the household) Mother’s Name: _________________________ Gross Monthly Amount: $______________ Father’s Name: _________________________ Gross Monthly Amount: $______________ Children: Name: _________________________________Gross Monthly Amount: $ _____________ Name: _________________________________Gross Monthly Amount: $ _____________ Name: _________________________________Gross Monthly Amount: $ _____________ Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Health Insurance Needs Medicaid SSI: _____Yes _____No 1619(b): _____Yes _____No California Threshold is: $29,040 1634(c): _____Yes _____No Pickle Amendment: _____Yes _____No Medicare Part A: _____Yes _____No {Hospitalization} Part B: _____Yes _____No {Outpatient} Does individual pay for Part B premium? _____Yes _____No If yes who pays for it?____________________________ How much? $___________________________________ Private Insurance Name of Company:______________________________ Monthly Amount Paid: $_________________________ IRWE’s Type of IRWE Nature of item/service Relation to disability&work Monthlycost Transportation Medication Health Ins. (premiums,co-pays, & deductibles) Attendant care at home Attendant care at work Medical devices Prosthetic devices Work related equipment Residential modifications to work away from home Residential modifications to work at home Medi-Cal Working While Disabled Program Other Blind Work Expenses (BWE’s) Is the individual legally blind? _____Yes _____No If yes, is the individual working? _____Yes _____No If yes, is the individual an SSI recipient? _____Yes _____No If yes, do BWE work up. If no, do work up for potential SSI eligibility using BWE’s. If legally blind and not currently working, explain potential for BWE’s. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Subsidies Yes No Is a government agency paying part of wage?-------------------------____ ____ Does the individual get special assistance on the job?--------------____ ____ Does the individual perform fewer duties than others?---------------____ ____ Does the employer accept less productivity than from others?------ ____ ____ Does the individual receive extra rest periods/breaks?----------- ____ ____ Is the individual frequently absent or working irregular hrs. because of disability? ____ ____ Does the individual receive job coach assistance?---------------- ____ ____ ***If yes to any of the above, describe:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Youth Waivers WAIVER APPLICABLE NON-APPLICABLE DATE APPLIED $3 for $4 Earned Income SEIE CDR or Age 18 Medical Re-determination Scheduled Date:____________ PASS IDA’s Benefit Plan for client: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________