Vocational and Work History (To be completed by applicant ...
[Pages:2]State of California--Health and Human Services Agency
VOCATIONAL AND WORK HISTORY
(To Be Completed By Applicant/Beneficiary)
Department of Health Care Services
Parent Number 1
Name: ____________________________________________________
List your employment and training history for the last two years. Begin with your current or latest job or training.
Name of Employer or Training Program
1.
Work or
When
Training Employed
Gross Amount Monthly
Work
From __/__/__
$
Training To __/__/__
Name of Employer or Training Program
4.
Work or
When
Training Employed
Gross Amount Monthly
Work
From __/__/__
$
Training To __/__/__
2.
Work
From __/__/__
5.
Work
From __/__/__
$
$
Training To __/__/__
Training To __/__/__
3.
Work
From __/__/__
6.
Work
From __/__/__
$
$
Training To __/__/__
Training To __/__/__
Parent Number 2
Name: ____________________________________________________
List your employment and training history for the last two years. Begin with your current or latest job or training.
Name of Employer or Training Program
1.
Work or
When
Training Employed
Gross Amount Monthly
Work
From __/__/__
$
Training To __/__/__
Name of Employer or Training Program
4.
Work or
When
Training Employed
Gross Amount Monthly
Work
From __/__/__
$
Training To __/__/__
2.
Work
From __/__/__
5.
Work
From __/__/__
$
$
Training To __/__/__
Training To __/__/__
3.
Work
From __/__/__
6.
Work
From __/__/__
$
$
Training To __/__/__
Training To __/__/__
MC 210 S-W (05/07)
Page 1 of 2
State of California--Health and Human Services Agency
MEDI-CAL U-PARENT DETERMINATION WORKSHEET
(To Be Completed By CWD Staff)
Department of Health Care Services
Case name: ______________________________________________ Worker number: _________________________
Case number:_____________________________________________ Date: __________________________________ 1. Determination of Principal Wage Earner (PWE)
a. Application date OR date U-Parent deprivation began: ____________ b. To establish 24-month earnings period, check month on chart for each parent:
Month number 1: subtract two years from line (a): ______________
Month number 24: Month/Year immediately preceding line (a): ______________
Parent 1's Earnings
__________________
Name
Current year ___________
Year __________
$
Dec.
$
Dec.
$
COUNTY $
Nov.
$
Nov.
$
$
Oct.
$
Oct.
$
$
Sep.
$
Sep.
$
$
Aug.
$
Aug.
$
$
Jul.
$
Jul.
$
$
Jun.
$
Jun.
$
$
May
$
May
$
$
$
Total: $_____________ $ $
Apr.
$
Apr.
$
USE Mar.
$
Feb.
$
Jan.
$
Mar. Feb. Jan.
$ $ $
Year __________
Dec. Nov. Oct. Sep. Aug. Jul. Jun. May Apr. Mar. Feb. Jan.
Parent 2's Earnings __________________
Name
Total: $_____________
Current year ___________
Year __________
$
Dec.
$
Dec.
$
Nov.
$
Nov.
$
Oct.
$
Oct.
$ $ $
ONLY Sep.
$
Aug.
$
Jul.
$
Sep. Aug. Jul.
$
Jun.
$
Jun.
$
May
$
May
$
Apr.
$
Apr.
$
Mar.
$
Mar.
$
Feb.
$
Feb.
$
Jan.
$
Jan.
Year __________
$
Dec.
$
Nov.
$
Oct.
$
Sep.
$
Aug.
$
Jul.
$
Jun.
$
May
$
Apr.
$
Mar.
$
Feb.
$
Jan.
The parent earning the greater amount is the PWE: _______________________________________________________
(Name of PWE)
2. Is the PWE working 100 hours or more a month?
Yes No
If "yes," complete the Unemployed Parent Worksheet (MC 337).
Note: If the PWE is a recipient of Section 1931(b), he/she may exceed 100 hours with no earned income test.
MC 210 S-W (05/07)
Page 2 of 2
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