Food Stamp Benefit Calculation

Branch: Case Number: - - Worker ID:
Case Name: Non-Citizen Calc

Date: Manuals:  Family Services SPD Program
Client Explanation:  English Spanish
Certified Prior to 3/1/2001: Yes

Benefits Paid

Net Allotment:
Overpayment Recovery:
Benefit Amount:   (Net Allotment + Overpayment Recovery)

Household Information

Categorically eligible: Yes
Number in Household:
Number Aged/Disabled:

Income Information

Reported Earned Income:
Unreported Earned Income:
Reported Unearned Income:
Unreported Unearned Income:
Reported Gross Self-Employment Income -
Without costs (SEN):
With costs (SEC):
Unreported Gross Self-Employment Income -
Without costs (SEN):
With costs (SEC):


Utilities (FUA, LUA, TUA or IUA)
STD/FUA: Yes  (STD prior to 10-1-2002)
LUA: Yes
TUA: Yes   (Effective 10-1-2004)
IUA: Yes   (Effective 10-1-2006)
Actual:   0.00 if no FUA/LUA.
Dependent Care:   Prior to 10-1-08 max age 2 or under = $200 - all others $175
Court Ordered Child Support:
Aged/Disabled Medical Expense:   Person #1
  Person #2
  Person #3
  Person #4
Total Medical Expenses:


EBT Adjustments:   (Including aged off benefits)
Adjustment for Prior Overpayment:   


Spanish Form221

         Rev. 10/2008