F 80130 Form – Fill Out and Use This PDF

Name – Client (Last, First, Middle)

Client No.

Facility (Abbreviate)

Service From – Date

Family Address – Street

City

State

Zip

Home Telephone No.

PART 1 – THIRD PARTY PAYERS – INSURANCE

Medical Assistance Number

M.A. Eligibility Dates

Medicare Number

V.A. / Champus Number

From:

To:

Name – Insurance Carrier

Name of Policy Holder

Subscriber Number

Insurance Carrier’s Address – Street

City

State

Zip

Group Number

Name – Insurance Carrier

Name of Policy Holder

Subscriber Number

Insurance Carrier’s Address – Street

City

State

Zip

Group Number

EARNED INCOME

Earnings come from employment or self-employment (farm or non-farm).

GROSS

Enter earnings for all persons except children in school.

AVERAGE

UNEARNED INCOME

See income definition list in DHS 1.01(2). Enter unearned income for all persons

MONTHLY

Client

(If client lives in substitute care facility, do not enter client income.)

INCOME

Birth Date

Social Security No.

Name – Employer

Work Telephone No. Earned

1a

Father of Minor Client

(Enter Stepfather information in lines 5a and 5b.)

Name

Social Security No.

Birth Date

Earned

3a

Mother of Minor Client

(Enter Stepmother information in lines 5a and 5b.)

Name

Social Security No.

Birth Date

Earned

4a

Others in Family

Is there income in lines 1a through 4b?

Yes, CONTINUE.

No, Skip to line 18 & enter 0.

Relatives in the home who are federal tax exemptions (siblings, stepparents, etc.)

● Enter earnings for all persons except children in school.

● Enter unearned income for all persons.

Name

Relationship to Client

Birth Date

Social Security No.

Earned

5a

Total Number of Persons Dependent on Family income for support.

10

Exclude persons for whom court ordered support is paid and persons living in care facilities.

MAXIMUM MONTHLY PAYMENT FROM TABLE.

11

Use the values in line 9 and line 10.

ADJUSTMENT TO MAXIMUM MONTHLY PAYMENT for income from non-liable parties.

Is there income reported on either line 5a or 5b?

(That is, from a person other than client, spouse, father, or mother?)

No – Copy the amount from line 11 to line 18. Skip lines 12 through 17.

Yes – Complete lines 12 through 17.

Total Average UNEARNED INCOME of the Client, Spouse, Father and Mother.

12

(This is, the total of lines 1b, 2b, 3b and 4b.)

Exclude client’s income in out of home placements.

Total Average EARNED INCOME of Client, Spouse, Father and Mother.

13

(This is, the total of lines 1a, 2a, 3a and 4a.)

Exclude client’s income in out of home placements.

Find one-half of the amount in line 13. Enter the result.

14

Add line 12 and line 14. Enter the result.

15

ALLOWANCES FOR WORK-RELATED EXPENSES.

1a

For each line in this workspace, enter the lesser of the amount in each earning line or $90.

2a

(For example if line 1a is $50, enter $50; if line 1a is $100, enter $90.)

3a

4a

Find the total of the allowances.

16

Subtract line 16 from line 15. Enter the result.

17

THE MAXIMUM MONTHLY PAYMENT MUST NOT EXCEED THIS AMOUNT.

ADJUSTED MAXIMUM MONTHLY PAYMENT: Enter the lesser of line 17 or line 11 if income is contributed by someone

18

other than the client, spouse, father, or mother. In all other cases, enter the amount from line 11.