OmniForm Form - Connecticut



Supplemental Nutrition Assistance Program (SNAP) Computation Sheet

W-1216 (Rev. 10/21)

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| # of SNAP |Amount |

|Members | |

| 1 | $250 |

| 2 | $459 |

| 3 | $658 |

| 4 | $835 |

| 5 | $992 |

| 6 | $1,190 |

| 7 | $1,316 |

| 8 | $1,504 |

- $      

Shelter Hardship

-----------------------

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STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES

STEP 1

STEP 2

Monthly Gross Earnings

Rent/Mortgage

minus

$

20% (not given on unreported income)

plus

$

20%

Utility Allowance (SUA $783, LUA $345, TUA $29)

equals

$

Adjusted Earned Income Unearned Income

equals

$

Total Shelter Expense

plus

$

minus

-

50% of the Adjusted Gross Income

equals

$

Total Income

equals

$

minus

Standard Deduction

(1-3 = $177, 4 = $184,

5 = $215, 6+ = $246)

Note: Shelter hardship cannot exceed $597 unless AU has member 60 or older, or disabled.

equals

$

Balance

minus

$

Medical expenses in excess of $35 if age 60 and older, or disabled

equals

$

Balance

minus

$

Dependent Care

minus

$

Other deductions (child support payments, etc.)

equals

$

Adjusted Gross Income

X .5

$

(.5 x AGI) Deduct from total shelter expense

STEP 3

THRIFTY FOOD PLAN

Adjusted Gross Income

TABLE *

minus

$

equals

$

Shelter Hardship from Step 2 Net Adjusted Income (NAI)

NAI x .30

$

If amount ends in .01 to .99, round up to the nearest whole dollar. (Enter amount on next line.)

''30% of Net Adjusted Income''

Thrifty Food Plan per table

minus

$

equals

$

SNAP Benefit

*Add $188 for each additional

SNAP household member.

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