SILP Resident Monthly Budget Worksheet
SILP Resident Monthly Budget Worksheet
Individual: Agency:
Does Individual have a Rep Payee? NO YES Identify:
|Step 1. INCOME | | | |
|SSI | | | |
|SSDI | |(own work history) | |
|SSB | |(retired/deceased parent?) | |
|Monthly Gross Wages (minus $65 in earning) | | | |
|Food Stamps | | | |
|Trust Income | | | |
|Rent Subsidy | | | |
|Other | | | |
|A. TOTAL INCOME | |
|STEP 2. BASIC EXPENSES | | | |
|Rent, Mortgage | | | |
|Renters/Other Insurance | |Describe |
|Groceries, Food Costs | | | |
|Phone | | | |
|Utilities | | | |
|Clothing/Personal Items | | | |
|Recreation/Leisure | | | |
|Cable | | | |
|Medical Costs | |(not covered) | |
|Transportation | | | |
|Other | |Describe |
|Are total expenses > $603? If “yes”, further counseling will be required. | |
|B. TOTAL EXPENSES | |
|A – B = C C. Available Resources | |
|MAY be used for comprehensive off-set or services purchased above Brokerage benefit level. |
|STEP 3 POSSIBLE ADJUSTMENTS TO C. AVAILABLE RESOURCES | |
|Medical cost Adjustments not covered by Medicaid or other insurance |
|(See SPD IM 06-015, 1/16/06) |
| Medical | | | |
| Dental | | | |
| Supplies/Equipment | | | |
| Prescriptions | | | |
| OT, PT | | | |
|Other Allowable Special Needs Adjustments | |
| Housekeeper Allowance | |(if on food stamps only) | |
| Guide Dog Allowance | | | |
| Laundry Allowance | |(costs if going to laundromat only) |
|Possible Employment Work Incentive Adjustments | |
|PASS | |
|IRWE | |
|D. TOTAL POSSIBLE ADJUSTMENTS | |
|C - D = E E. SUPPORTED LIVING RESIDENTIAL OFF SET | |
This information will be used in Individual Counseling and Choice Sessions
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