NYC SNAP BUDGET WORKSHEET

Number in Family/Household: ____________ A. INCOME 1. 2. 3. 4. Monthly Gross Earned Income (salary, self-employment, etc.) Monthly Income from Boarder/Lodger/Rental Property (exclude first $200 for a single, $367 for a couple) Monthly Earned Income (Add lines 1+2) a. Monthly gross Unearned Public Assistance Income b. Monthly gross Unearned RSI/SSDI/SSI c. Monthly gross Unearned "Other Income (child support, UIB, pensions, etc.) d. Net monthly rental income 5. 6. 7. Monthly Unearned Income (Add lines 4a + 4b + 4c + 4d) Legally obligated child support payments that the household pays (subtract from total income) Adjusted Gross Income (Add lines 3+5, minus line 6) 1 __________ 2 __________ 3 __________ 4a __________ 4b __________ 4c __________ 4d __________ 5 __________ 6 __________ A.7__________ Line A.7 must be less than line B B. _________ Any Elderly (60+)/Disabled Member? Yes ___ No ___

B. MAXIMUM GROSS MONTHLY INCOME TEST - See chart on back. Households with an elderly or disabled person do not have a maximum gross income test. Working households that incur un-reimbursed child care/dependent care costs have a gross income test of 200% FPL. All other households have a gross income test of 130% FPL. C. DEDUCTIONS 8. 9. Deduction on Gross Earned Income (20% x Line 3) Standard Deduction based on household size, (enter applicable amount) Household size 13 4 5 6 and over Deduction $152 $163 $191 $219

8__________

9__________

10. Child Care/Dependent Costs: Actual cost to the household for the care of a child or dependant. 11. Homeless Income Deduction - $143 (if undomiciled and not in continuous shelter) 12. Medical expense deductions only for Elderly/Disabled members. Take the total average monthly unreimbursed medical expenses, and subtract the first $35. 13. Total Deductions (Add lines 8 + 9 + 10+ 11 + 12) D. ADJUSTED INCOME (Line A.7 - Line C.13)

10_________ 11 _________ 12 _________ C .13 ________ D. _________

As of November 1, 2013

NYC SNAP BUDGET WORKSHEET

E. MONTHLY SHELTER COSTS 14. Amount household pays for rent/mortgage 15. Standard Utility Allowance (SUA) Levels in NYC. Enter amount for SUA level. Level 1 - $753 Has heating/cooling costs, or has received HEAP, or is living in HEAP eligible housing & anticipates the receipt of HEAP. Level 2 - $298 Ineligible for or did not receive HEAP for the current program year, has no heating/cooling cost, but has utility costs. Level 3 - $33 Ineligible for or did not receive HEAP for the current program year, has no heating/cooling or utility costs, but has phone. 16. Other Owned-Property Shelter Costs: Taxes, Insurance, Repairs 17. Total Shelter Cost (Add lines 14+ 15+ 16) F. EXCESS SHELTER DEDUCTIONS 18. Total Shelter Cost = Line E.17 19. One-Half of Adjusted Income = Line D divided by 2 20. Shelter Deduction = Line 18 minus Line 19. If negative enter $0 21. For non-elderly/non-disabled households enter the amount on line 20, up to a maximum of $478. For elderly/disabled households enter the full amount on line 20. If a negative number, enter $0. G. SNAP NET INCOME 22. Adjusted Income = Line D 23. Maximum Excess Shelter Deduction = Line F.21 24. Monthly Net SNAP Income (Line 22 minus Line 23) H. SNAP ENTITLEMENT 25. Enter Thrifty Food Plan amount for H.H. size (See Chart below) 26. Multiply Net SNAP Income by 30% (Line G.24 x .30) 27. SNAP Recoupment (if applicable) 28. SNAP COUPON ALLOTMENT (Line 25 minus Line 26 minus Line 27) 25_________ 26 _________ 27 _________ H. 28________ 22 _________ 23 _________ G. 24 ________ 20 _________ F. 21_______ 14_________

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16_________ E.17________ 18 ________ 19 _________

November 1, 2013 - September 30, 2014 Max. Gross Monthly Income for Non-Elderly/Non-Disabled HH's 130% FPL $1,245 1,681 2,116 2,552 2,987 3,423 3,858 4,294 +$436 Max. Gross Monthly Income for HHs with Out-of-Pocket Child/Dependent Care Costs 200% FPL $1,915 2,585 3,255 3,925 4,595 5,265 5,935 6,605 +670

HH Thrifty Food Plan Monthly Amount 1 2 3 4 5 6 7 8 $189 $347 $497 $632 $750 $900 $995 $1.137

Each add/l member: + $142

As of November 1, 2013