Mc 14A Form PDF Details

Are you looking to understand what the IRS Mc 14A form is and how it affects your taxes? You're in the right place. This blog post is going to provide an overview of what this form is, why you may need to file it, and how filing it can help reduce your tax burden. We’ll also answer some common questions about filing a Mc 14A and explain who needs to get one. Whether you are new to filing taxes or have been dealing with them for years, this article should help clarify any confusion surrounding a Mc 14A Form.

QuestionAnswer
Form NameMc 14A Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmc 14 a, unearned, INCOMEadd, QMB

Form Preview Example

State of California—Health and Human Services Agency

Department of Health CARE Services

QUALIFIED MEDICARE BENEFICIARY (QMB),

SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (SLMB),

AND QUALIFYING INDIVIDUALS (QI) APPLICATION

 

 

 

 

 

 

 

 

 

Name

 

 

Social security number

Medicare number

 

Date

 

 

 

 

 

 

 

 

Telephone number

Date of birth

 

Sex

Marital status

❒ Married

❒ Divorced

(

)

 

 

❒ Male ❒ Female

❒ Separated

❒ Single

❒ Widowed

 

 

 

 

 

 

 

 

Address (number, street)

 

 

City

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

This information is to help you apply for the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or the Qualifying Individual-1 (QI-1) programs. The State will pay Medicare Parts A and B premiums, deductibles, and coinsurance fees for persons eligible for the QMB program. The State will pay Medicare Part B premiums for persons eligible for SLMB or QI-1. You may apply for QMB, SLMB, or QI-1 by completing and mailing this form to your local county social services agency.

To be eligible for QMB, SLMB, or QI-1, you must:

�Be eligible for Medicare Part A (hospital insurance).

�Be eligible for Medicare Part B (medical insurance).

�Meet the following income requirements:

�QMB: Net countable income at or below 100% of the Federal Poverty Level (FPL) (at or below $908* for a single person, or $1,226* for a couple).

�SLMB: Net countable income below 120% of the FPL (below $1,089* for a single person, or $1,471* for a couple).

�QI-1: Net countable income below 135% of the FPL (below $1,226* for a single person, or $1,655* for a couple).

*If you have a child living in the home with you, these amounts may be higher. These amounts are expected to increase each year in April. If you received a Title II Social Security cost of living adjustment in January, this amount will not be counted until April.

�Have no more than $6,680 in nonexempt property for a single person, or $10,020 for a couple.

�Meet certain requirements and conditions, such as being a resident of California.

IMPORTANT:

 

 

You may be eligible for other Medi-Cal programs in addition to the QMB and SLMB programs, such as food

❒ Yes

❒ No

stamps and/or Medi-Cal with a monthly spenddown (share-of-cost). You may also be eligible for Medi-Cal

 

 

with a monthly share-of-cost if you are over the income limits of the QMB, SLMB, and QI-1 programs. This

 

 

coverage would include payment of the Medicare Part B premium. If you wish to apply for these other

 

 

programs, check yes and the county will send you other forms to complete.

 

 

Do you wish to apply for three months of retroactive coverage for the SLMB and QI-1 programs (there IS NO

❒ Yes

❒ No

retroactive coverage for QMB).

 

 

List all persons living in your household (spouse/children). If you have more than three persons living with you, you may list them on a separate page.

Name

 

Sex

 

 

 

M=Male

 

 

Social Security Number

F=Female

Date of Birth

Relationship to You

MAIL COMPLETED FORM TO YOUR COUNTY SOCIAL SERVICES AGENCY.

(ADDRESSES ON BACK SIDE OF THIS FORM)

MC 14 A(09/11)

Page 1 of 3

A. COUNTABLE INCOME

1. Fill in the MONTHLY unearned income received by the QMB/SLMB/QI-1 applicant:

a.

Social security check

$_______________

b.

VA benefits

$_______________

c.

Interest from bank accounts or certificate(s) of deposit

$_______________

d.

Retirement income

$_______________

e.

Any other unearned income

$_______________

f.

Total UNEARNED INCOME—add lines a. through e.

$_______________

2.If you are married and living with your SPOUSE, fill in the MONTHLY unearned income received by your spouse:

g.

Social security check

$_______________

h.

VA benefits

$_______________

i.

Interest from bank accounts or certificate(s) of deposit

$_______________

j.

Any other unearned income

$_______________

k.

Retirement income

$_______________

l.

Total SPOUSE’S UNEARNED INCOME—add lines g. through k.

$_______________

3.Fill in the MONTHLY earned income received by the QMB/SLMB/QI applicant and spouse:

m. Gross earnings for the person who wants to be a QMB,

 

 

SLMB, or QI-1

$_______________

n.

Gross earnings for the spouse

$_______________

o.

Total—add lines m. and n.

$_______________

p.

Subtract $65

$_______________

q.

Remainder

$_______________

r.

Divide by 2

$_______________

s.

Total EARNED AND UNEARNED INCOME—

$_______________

 

add lines f., l., and r.

 

4. Potential QMB, SLMB, or QI-1 eligibles:

COUNTY USE

Applicant’s

 

unearned

 

income

 

(line f)

$____________

Spouse’s

 

unearned

 

income

 

(line l)

+____________

 

____________

Any

 

income

 

deduction

-____________

Net

 

unearned

 

income

____________

Net

 

earned

 

income

 

(line r)

+____________

Total

 

net income

____________

MFBU size

____________

Compare to QMB/SLMB/QI-1/QI-2 income limit.

If over income limit, is there a spouse and/or children in the home? Complete the MC 176-2 A QMB/SLMB/QI form.

�You are potentially eligible as a QMB if your income is at or below 100% of the FPL (at $908* for a single person, or at $1,226* for a couple.

�You are potentially eligible as a SLMB if your income is below 120% of FPL (below $1,089* for a single person, or below $1,471* for a couple).

�You are potentially eligible as a QI-1 if your income is below 135% of FPL (below 1,226* for a single person, or below $1,655* for a couple).

*If you have a child in the home, these amounts may be higher.

MC 14 A (09/11)

Page 2 of 3

B.PROPERTY

A QMB, SLMB, or QI-1 who is not married or not living with his/her spouse may have countable property which is equal to or less than $6,600. A QMB, SLMB, or QI-1 who is married and living with his/her spouse must have countable property which is equal to or less than $9,910.

The following are examples of countable property. Important: The home you and/or a spouse live in doesnotcount. One car used for transportation does not count. If you apply at the county welfare department as a QMB, SLMB, or QI-1, the county may treat the property listed on this form differently. There are other types of property which the county welfare department, will also look at, i.e., certificates of deposit. This other property may or may not count towards the property limit.

Fill in the value of the following property which belongs to you, your spouse, or both of you.

1.

Checking accounts

$_______________

2.

Savings accounts

$_______________

3.

Certificate(s) of deposit

$_______________

4.

Stocks

$_______________

5.

Bonds

$_______________

6.

A second car (value minus amount owed)

$_______________

7.

A second home (value minus amount owed)

$_______________

8.The cash surrender value of life insurance policies if the face value of all policies combined exceeds $1,500

(Do not include “term” insurance policies)

$_______________

9. Total PROPERTY—add lines 1 through 8

**$_______________

**This total cannot exceed $6,680 for a single person or $10,020 for a couple.

COUNTY USE

Additional information: You may be eligible for up to three months of retroactive coverage of your Medicare Part B premiums under the SLMB and QIprograms.

NOTE: Individuals enrolled in traditional Medi-Cal, in addition to the QMB/SLMB/QIprograms, may be subject to Estate Recovery. Medi-Cal benefits received by an individual after age 55 may be recoverable by the State. Recovery may be made from the estate or the distributee/heir of the Medi-Cal beneficiary if the beneficiary does not leave a surviving spouse, minor children, or a totally disabled or blind son or daughter.

Individuals enrolled in only the QMB/SLMB/QIprograms, however, are not subject to Estate Recovery.

I declare under penalty of perjury, under the laws of the United States of America and the State of California, that information I have given on this form is true, correct, and complete.

Signature (or mark) of applicant

➤

Date

COUNTY USE

� QMB approved

� SLMB approved

� QI-1 approved

� QMB/SLMB/QI-1 denied

Eligibility Worker’s signature

➤

Date

Privacy Statement

This information given in this application is private and confidential under Welfare and Institutions Code 14100.2. This information will be disclosed only in accordance with those laws.

Sections 14011 and 14012 of the Welfare and Institutions Code allow county welfare departments to get certain facts from you, or the person(s) you represent, so that you can get Medi-Cal benefits. You must provide these facts to get some or all of your Medicare costs paid by Medi-Cal. You are required to provide your Social Security Number under the Social Security Act, Section 1137(a)(1) and the Welfare and Institutions Code, Section14011.2.

MC 14A (09/11)

Page 3 of 3

How to Edit Mc 14A Form Online for Free

If you would like to fill out QI, you don't need to install any kind of software - simply give a try to our online PDF editor. Our tool is continually evolving to give the very best user experience possible, and that's because of our commitment to constant improvement and listening closely to comments from customers. To get the process started, go through these simple steps:

Step 1: Hit the "Get Form" button in the top area of this page to access our PDF editor.

Step 2: With our online PDF editor, it is possible to do more than merely complete forms. Edit away and make your documents appear sublime with custom text added in, or adjust the original content to perfection - all backed up by an ability to incorporate any kind of images and sign the PDF off.

When it comes to blank fields of this particular document, here's what you need to know:

1. Firstly, when filling in the QI, start out with the section that has the subsequent fields:

Filling out section 1 of unearned

2. The subsequent part would be to fill in these blanks: IMPORTANT You may be eligible for, List all persons living in your, Name, Social Security Number, Sex, MMale, FFemale, Date of Birth, Relationship to You, MAIL COMPLETED FORM TO YOUR COUNTY, ADDRESSES ON BACK SIDE OF THIS FORM, MC A, and Page of.

Filling in segment 2 of unearned

Be extremely careful when filling out MC A and Date of Birth, since this is the section in which many people make errors.

3. In this stage, look at Fill in the MONTHLY unearned, COUNTY USE, a Social security check, b VA benefits, Interest from bank accounts or, d Retirement income, e Any other unearned income, f Total UNEARNED INCOMEadd lines a, Applicants unearned income line f, Spouses unearned income line l, If you are married and living with, g Social security check, h VA benefits, Any income deduction, and Interest from bank accounts or. All of these will need to be filled in with utmost precision.

Part no. 3 for completing unearned

4. This next section requires some additional information. Ensure you complete all the necessary fields - m Gross earnings for the person, SLMB or QI, n Gross earnings for the spouse, o Totaladd lines m and n, p Subtract, q Remainder, r Divide by, s Total EARNED AND UNEARNED INCOME, add lines f l and r, Potential QMB SLMB or QI eligibles, Total net income, MFBU size, Compare to QMBSLMBQIQI income limit, If over income limit is there a, and You are potentially eligible as a - to proceed further in your process!

unearned completion process explained (portion 4)

5. This very last step to conclude this form is pivotal. Ensure to fill in the displayed form fields, and this includes Checking accounts, Savings accounts, Certificates of deposit, Stocks, Bonds, A second car value minus amount, A second home value minus amount, The cash surrender value of life, the face value of all policies, Total PROPERTYadd lines through, This total cannot exceed for a, and Additional information You may be, before finalizing. Failing to do this can give you an unfinished and possibly incorrect paper!

Best ways to fill in unearned portion 5

Step 3: Before moving forward, ensure that all blanks are filled in the right way. When you verify that it's fine, press “Done." After creating afree trial account here, you will be able to download QI or email it promptly. The PDF document will also be readily accessible in your personal cabinet with your changes. FormsPal provides protected document tools with no data record-keeping or sharing. Feel at ease knowing that your information is in good hands here!

Mc 14A Form isn’t the one you’re looking for?

Related Documents