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N.Y.C. FOOD STAMP BUDGET WORKSHEET
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Number in Household: |
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Any Elderly (60+)/Disabled Member? |
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INCOME |
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Monthly Gross Earned Income(salary, self-employment, etc.) |
$ |
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Net Monthly Income from Boarder/Lodger/Rental Property: up to $162 deduction for a single person, $298 for a couple. Please use the Boarder/Lodger Worksheet |
$ |
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Monthly gross Unearned Public Assistance Income |
$ |
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Monthly gross Unearned RSI/SSD/SSI |
$ |
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Monthly gross Unearned "Other Income" |
$ |
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Child Support Payments(actually paid, legally obligated amounts) |
$ |
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Adjusted Gross Income |
$
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MAXIMUM GROSS MONTHLY INCOME TEST - see chart for correct family size.
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$
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DEDUCTIONS |
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Child Care/Dependent Costs: up to $200 for each child under 2, up to $175 for children 2 and over or other
dependents. Please use the Child Care Worksheet
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$ |
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Is this household homeless undomiciled and not in continuous shelter? |
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Medical expense deductions only for Elderly/Disabled members. Take the total average monthly
unreimbursed medical expenses. |
$ |
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MONTHLY SHELTER COSTS |
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Actual rent/mortgage billed to the household |
$ |
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Where do you live? |
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Standard Utility Allowance(SUA) Levels
Level 1 - $577: Has heating/cooling or received or anticipates receipt of HEAP for the current program year
Level 2 - $256: Ineligible for or did not receive HEAP for the current program year, has no heating/cooling costs, 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
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Other Owned-Property Shelter Costs: Taxes, Insurance, Repairs |
$ |
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FOOD STAMP NET INCOME |
$ |
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FOOD STAMP ENTITLEMENT |
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Thrifty Food Plan amount for H.H. size(See below) |
$ |
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Food Stamp Recoupment (if applicable) |
$ |
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Potential Food Stamp Allotment |
$ |
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