Countable Income Types: Category: Type: Acceptable ...

1 Countable Income Types: Category: Type: Acceptable Documentation of Income : Supplemental Security Income (SSI). Award/Benefit Letter (dated in the same year (See ). as the application or the previous calendar Social Security Disability Insurance year with clarification of current amounts). (SSDI) (See ). Payment Printout/statement from issuing Fixed Social Security Retirement (SS) (See agency Countable ). Copy of Check or Bank Statement showing Income Pension (examples are government, deposit military and private). Most recent IRS Form 1099. Widow/Widower's benefit Most recent filed copy of IRS Form 1040 or Alimony Tax Transcript Black Lung pension All pay stubs received 30 days from the date of the application that include gross and/or Earned Wages (salary, tips, commission, year-to-date amounts received Countable bonuses, etc.)

2 Completed and signed Employment Income Verification Form (Appendix VI). Active Military Pay Check Stub/Pay Statement Pay stubs indicating amount received within Seasonal Employment (includes the previous 12 months from the date of the construction workers, teachers, application landscapers, etc.) Seasonal Employment Verification Form(Appendix VII). Most recent filed copy of IRS Form 1040 and Schedule 1 for tax year 2018 use the amount Other Earned listed on line 12, 17 and/or 18; for tax year Countable 2019 use the amount listed on line 3, 5 and Income Self-employment (includes owning 6. own business, babysitting, home Most recent IRS Record of Account party sales, odd jobs, ohio Electronic Transcript Child Care, etc.)

3 Self-Employment Income and Expense Form (Appendix V) for the previous 12 months and an IRS Verification of Non-Filing Letter (if applicable). Copy of check ohio Department of Job and Family Services Unemployment documents/Eligibility letter with amounts and dates Most recent IRS Form 1099. Utility Assistance Housing Authority Documentation Supplemental Countable Award letter from issuing agency (Bureau of Income Workers' Compensation Workers' Compensation (BWC), etc.). Copy of check or bank statement Award/Benefit Letter, or ohio Works First (Temporary Payment Printout/Statement from issuing Assistance for Needy Families agency, or (TANF), Aid to Dependent Children) Copy of Check or Bank Statement showing deposit Countable Income Types Continued: Category: Type: Acceptable Documentation of Income : Supplemental Employment Disability Payouts ( Award Letter Countable Short-Term or Long-Term Disability Pay Stubs Income Payouts).

4 Continued Strike Benefit Pay Stubs Cash withdraws from: Individual Retirement Accounts, Annuities, Statement from Financial Institution Other investments Other Copy of Check or Bank Statement showing Lump sum payout from: Estate &. Countable deposit Trust settlements, Divorce Income Most recent IRS Form 1099. settlements, insurance payout, lottery winnings Interest Income No Income : Category: Type: Acceptable Documentation of Income : *Self-Declaration of Income Worksheet (Appendix IV). An IRS tax transcript or an IRS Verification of *Only required if there is no Countable or Non-Filing Letter No Income excluded Income in the household.

5 Additional documentation related to household composition and/or Income may be provided by the client at the discretion of the EAP. Deductions: Category: Type: Acceptable Documentation of Income : Health Insurance Premiums (Dental, Health and Vision Insurance). Short- and Long-Term Disability Copy of Premium Statement showing Premiums (Aflac, supplemental, etc.) payment Prescription plans Proof of Payment ( cancelled check or Health Care Spending Accounts paystub). Medicaid Spend Down (deductibles). Medicare Premiums Proof of Payment ( cancelled check or Deductions Child Support paid-out paystub identifying garnishment).

6 Attorney fees for estate or trust Proof of Payment ( cancelled check settlements Most recent filed copy of IRS Form 1040. Self-employment IRS allowable Self-Employment Income and Expense Form business expenses and IRS Verification of Non-Filing Letter (if applicable). Reimbursement for work expenses Pay Statement ( travel, mileage, meals, etc.). Excluded Income : Category: Type: Acceptable Documentation of Income : All pay stubs received 30 days from the date Census Wages of the application that include gross and/or year-to-date amounts received Signed statement from provider of gift Gifts indicating amount and frequency, provider name, address, and phone number Official notification of loan on institution letterhead including loan amount and repayment terms from issuing financial Loans institution Education assistance (grants Signed statement from lender indicating stipends for tuition/books))

7 Amount and payment terms, lender's name, address, and phone number School documentation demonstrating education assistance amount Child Support Received Award/Benefit Letter, or Payment Printout/. Excluded Stipends for foster care Statement from issuing agency, or copy of Income *. Adoption Assistance canceled Check or Bank Statement Award/Benefit Letter (dated in the same year *Only as the application or the previous calendar documented SS/SSI and SSDI Overpayments year). if the Payment Printout/Statement from issuing household's agency total Eligible Income Statement from issuing agency Award Letter with Benefit Amounts ( Countable Service Connected Veterans Income Bank Statement (if Income type is specified).)

8 Disability, VA. Deductions) Special Monthly Compensation (SMC), Compensation/Dependent Indemnity is below the Person Care Services/Caregiver Stipend Compensation (DIC). required Program which should be treated as a live-in threshold. aide Work programs for people with disabilities ( work programs for the blind or disabled). Workforce Investment Opportunity Act (WIOA) (Stipends provided for specific purposes other than Living Allowances) Award/Benefit Letter, or Payment Volunteers in Service to America Printout/Statement from issuing agency, Pay Stipend (VISTA) Statement Work allowances (work requirement to receive ohio Works First (OWF).

9 Assistance). Title V wages ( senior employment programs). ohio waiver program (Medicaid benefit for caregiver). All pay stubs received 30 days from the date of the application that include gross and Income earned by dependent minors year-to-date amounts received Completed and signed Employment Verification Form (Appendix VI). Excluded Income : Category: Type: Acceptable Documentation of Income : Tax refunds/rebates Most recent IRS Form Award/Benefit Letter, or Payment Printout/. Military allowances for subsistence statement from issuing agency Prevention retention and contingency ( emergency services, rental asst.

10 Excluded Award/Benefit Letter, or Payment Printout/. FEMA, cash payments Income Statement from issuing agency Title III Disaster relief emergency Continued assistance ( Stimulus payment). Payment Printout/Statement from issuing Proceeds from reverse mortgage agency Fair market value of services in lieu of Signed Statement from landlord rent Lease/Rental Agreement