Medi Cal Redetermination Form PDF Details

The Medi Cal Redetermination Form is a crucial form that is used to determine eligibility for the Medi-Cal program. This form must be completed by all applicants and renewal applicants, and any changes in income or household composition must be reported as soon. The information on this form will help determine whether an individual or family is eligible for Medi-Cal, and how much assistance they will receive. Make sure to complete this form accurately and thoroughly to ensure the best possible outcome for you or your family.

This figure features information about medi cal redetermination form. It might be beneficial to know its size, the actual time needed to complete the form, the fields you'll have to fill in, etc.

QuestionAnswer
Form NameMedi Cal Redetermination Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmedi cal redetermination, annual redetermination recertification, dpss lacounty gov annual redetermination en español, medi cal forms online

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No If no, highest grade completed (specify): Degree(s) obtained (specify):
Degree(s) obtained (specify):

FL-150

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

 

TELEPHONE NO.:

 

 

 

E-MAIL ADDRESS (Optional):

 

 

ATTORNEY FOR (Name):

 

 

 

 

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

 

 

STREET ADDRESS:

 

 

MAILING ADDRESS:

 

 

CITY AND ZIP CODE:

 

 

BRANCH NAME:

 

 

 

 

 

PETITIONER/PLAINTIFF:

 

RESPONDENT/DEFENDANT:

 

OTHER PARENT/CLAIMANT:

 

 

INCOME AND EXPENSE DECLARATION

CASE NUMBER:

 

 

 

 

 

1.Employment (Give information on your current job or, if you're unemployed, your most recent job.)

 

a.

Employer:

 

 

 

 

 

Attach copies

b.

Employer's address:

 

 

 

 

 

of your pay

 

 

 

 

 

c.

Employer's phone number:

 

 

 

 

stubs for last

 

 

 

 

d.

Occupation:

 

 

 

 

 

two months

 

 

 

 

 

(black out

e.

Date job started:

 

 

 

 

 

social

f.

If unemployed, date job ended:

 

 

 

 

security

 

 

 

 

g.

I work about

hours per week.

 

 

 

 

numbers).

 

 

 

 

 

 

 

 

 

 

 

 

h.

I get paid $

gross (before taxes)

 

per month

 

per week

 

 

 

per hour.

(If you have more than one job, attach an 8½-by-11-inch sheet of paper and list the same information as above for your other jobs. Write "Question 1—Other Jobs" at the top.)

2.Age and education

a.My age is (specify):

b. I have completed high school or the equivalent: Yes c. Number of years of college completed (specify):

d. Number of years of graduate school completed (specify):

e.I have: professional/occupational license(s) (specify):

vocational training (specify):

3.Tax information

a. I last filed taxes for tax year (specify year):

b.

My tax filing status is

 

 

 

single

 

 

 

head of household

 

 

married, filing separately

 

 

 

 

 

c.

 

married, filing jointly with (specify name):

 

 

I file state tax returns in

 

 

 

 

California

 

 

 

other (specify state):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.I claim the following number of exemptions (including myself) on my taxes (specify):

4.Other party's income. I estimate the gross monthly income (before taxes) of the other party in this case at (specify): $ This estimate is based on (explain):

(If you need more space to answer any questions on this form, attach an 8½-by-11-inch sheet of paper and write the question number before your answer.) Number of pages attached:

I declare under penalty of perjury under the laws of the State of California that the information contained on all pages of this form and any attachments is true and correct.

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF DECLARANT)

Page 1 of 4

Form Adopted for Mandatory Use

Judicial Council of California FL-150 [Rev. January 1, 2007]

INCOME AND EXPENSE DECLARATION

Family Code, §§ 2030–2032, 2100–2113, 3552, 3620–3634, 4050–4076, 4300–4339 www.courtinfo.ca.gov

Name of business (specify): Type of business (specify):
Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your social security number. If you have more than one business, provide the information above for each of your businesses.
Additional income. I received one-time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and amount):

FL-150

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT/CLAIMANT:

CASE NUMBER:

Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal tax return to the court hearing. (Black out your social security number on the pay stub and tax return.)

5.Income (For average monthly, add up all the income you received in each category in the last 12 months and divide the total by 12.)

a.

Salary or wages (gross, before taxes)

. .

. . .

.

 

. .

. . . . . . . . . . .

 

. . .

 

. . . . . . . . . . . . . . . . . $

b.

Overtime (gross, before taxes)

. . .

.

 

. .

. . . . . . . . . . .

 

. . .

.

. . . . . . . . . . . . . . . . $

c.

Commissions or bonuses

. .

. .

 

. .

. . . . . . . . . .

.

. . .

 

. . . . . . . . . . . . . . . . . $

d.

Public assistance (for example: TANF, SSI, GA/GR)

 

 

 

 

 

currently receiving

. . . . . . . . . . . . . . . . . $

 

 

 

 

 

 

 

 

 

 

e.

Spousal support

 

 

 

 

 

from this marriage

 

 

from a different marriage .

. . . . . . . . . . . . . . . . . $

 

 

 

 

 

 

 

 

 

 

 

f.

Partner support

 

 

 

 

 

from this domestic partnership

 

 

from a different domestic partnership $

g.

Pension/retirement fund payments

. .

.

 

. . .

. . . . . . . . . .

 

. . . .

 

. . . . . . . . . . . . . . . . . $

h.

Social security retirement (not SSI)

. .

.

.

. .

. . . . . . . . . .

 

. . . .

 

. . . . . . . . . . . . . . . . . $

i.

Disability:

 

 

Social security (not SSI)

 

 

 

 

State disability (SDI)

 

 

 

Private insurance . $

 

 

 

 

 

 

 

 

 

j.

Unemployment compensation

. .

.

 

. . .

. . . . . . . . . .

 

. . . .

 

. . . . . . . . . . . . . . . . . $

k.

Workers' compensation

. .

.

.

. .

. . . . . . . . . .

 

. . . .

 

. . . . . . . . . . . . . . . . . $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l.

Other (military BAQ, royalty payments, etc.) (specify):

. . . . . . . . . .

 

. . . .

 

. . . . . . . . . . . . . . . . . $

Average Last month monthly

6.Investment income (Attach a schedule showing gross receipts less cash expenses for each piece of property.)

a. Dividends/interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Rental property income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c. Trust income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ d. Other (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

7. Income from self-employment, after business expenses for all businesses. . . . . . . . . . . . . . . . . . . . . $

I am the owner/sole proprietor business partner other (specify):

Number of years in this business (specify):

8.

9. Change in income. My financial situation has changed significantly over the last 12 months because (specify):

10. Deductions

Last month

a. Required union dues

$

 

 

b.

Required retirement payments (not social security, FICA, 401(k), or IRA)

 

 

$

 

 

c.

 

 

Medical, hospital, dental, and other health insurance premiums (total monthly amount)

$

 

 

 

 

 

d.

Child support that I pay for children from other relationships

$

 

 

 

 

e.

Spousal support that I pay by court order from a different marriage

$

 

 

 

 

f.

Partner support that I pay by court order from a different domestic partnership

$

 

 

 

 

g.

Necessary job-related expenses not reimbursed by my employer (attach explanation labeled "Question 10g")

$

 

 

 

 

11. Assets

 

 

 

 

Total

 

 

 

 

 

a. Cash and checking accounts, savings, credit union, money market, and other deposit accounts

$

 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .b. Stocks, bonds, and other assets I could easily sell

$

 

 

c. All other property,

 

real and

 

personal (estimate fair market value minus the debts you owe)

$

 

 

 

 

 

 

 

 

 

FL-150 [Rev. January 1, 2007]

INCOME AND EXPENSE DECLARATION

Page 2 of 4

FL-150

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT/CLAIMANT:

CASE NUMBER:

12.The following people live with me:

 

 

How the person is

That person's gross

Pays some of the

 

Name

Age

related to me? (ex: son)

monthly income

household expenses?

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

b.

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

c.

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

 

 

 

 

 

Yes

 

 

 

 

No

e.

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Average monthly expenses

 

 

 

 

Estimated expenses

 

 

 

Actual expenses

 

Proposed needs

 

 

 

 

 

 

 

 

a.

Home:

 

 

 

 

 

 

 

 

 

 

 

 

h.

Laundry and cleaning

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1)

 

 

 

Rent or

 

 

mortgage

. $

 

 

i.

Clothes

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

j.

Education

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If mortgage:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)

average principal: $

 

 

 

 

 

k.

Entertainment, gifts, and vacation

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)

average interest:

$

 

 

 

 

 

 

 

l.

Auto expenses and transportation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2)

 

Real property taxes

. . .

. . .

. .

$.

 

 

 

 

(insurance, gas, repairs, bus, etc.)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3) Homeowner's or renter's insurance

 

 

 

 

m.

Insurance (life, accident, etc.; do not

 

 

 

 

 

 

 

 

 

 

include auto, home, or health insurance)

$

 

 

 

 

 

(if not included above)

 

 

 

 

$

 

 

 

 

 

 

 

(4)

 

. .

. . .

. . .

. . .

 

 

n.

Savings and investments

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maintenance and repair

$

 

 

 

 

 

 

 

 

o.

Charitable contributions

 

$

 

 

b.

Health-care costs not paid by insurance

$

 

 

 

 

 

 

p.

Monthly payments listed in item 14

 

 

 

c.

Child care

 

 

 

.

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. . .

. . . .

.

 

 

 

 

(itemize below in 14 and insert total here). .

$

 

 

 

 

 

 

 

 

 

 

 

 

d.

. . . . . .Groceries and household supplies

. $

 

 

q.

. . . . . . . . . . . . . . . . . . . . . .Other (specify):

$

 

 

 

 

 

 

 

 

 

 

 

 

 

e.

Eating out

 

 

 

.

$

 

 

 

 

 

 

 

 

 

 

 

. . .

. . . .

.

 

 

r.

TOTAL EXPENSES (a–q) (do not add in

 

 

 

f.

Utilities (gas, electric, water, trash)

 

 

 

 

 

 

 

$.

 

 

 

 

the amounts in a(1)(a) and (b))

$

 

 

 

 

 

 

 

 

g.

Telephone, cell phone, and e-mail

$

 

 

 

 

 

 

 

 

 

 

 

 

 

s.

Amount of expenses paid by others

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.Installment payments and debts not listed above

Paid to

For

Amount

Balance

Date of last payment

 

 

$

$

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

15.Attorney fees (This is required if either party is requesting attorney fees.):

a.To date, I have paid my attorney this amount for fees and costs (specify): $

b.The source of this money was (specify):

c.I still owe the following fees and costs to my attorney (specify total owed): $

d.My attorney's hourly rate is (specify): $

I confirm this fee arrangement.

Date:

(TYPE OR PRINT NAME OF ATTORNEY)

(SIGNATURE OF ATTORNEY)

FL-150 [Rev. January 1, 2007]

INCOME AND EXPENSE DECLARATION

Page 3 of 4

FL-150

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT/CLAIMANT:

CASE NUMBER:

CHILD SUPPORT INFORMATION

(NOTE: Fill out this page only if your case involves child support.)

16.Number of children

a. I have (specify number): children under the age of 18 with the other parent in this case.

b. The children spend percent of their time with me and percent of their time with the other parent.

(If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.)

17.Children's health-care expenses

a.

 

I do

 

I do not

have health insurance available to me for the children through my job.

b.Name of insurance company:

c.Address of insurance company:

d.The monthly cost for the children's health insurance is or would be (specify): $ (Do not include the amount your employer pays.)

18. Additional expenses for the children in this case

Amount per month

 

 

 

a. Child care so I can work or get job training

$

 

 

 

 

 

 

 

 

 

 

 

b. Children's health care not covered by insurance

$

 

 

 

 

 

 

 

 

 

 

 

 

c. Travel expenses for visitation

$

 

 

 

 

 

 

d. Children's educational or other special needs (specify below):

$

 

 

 

 

 

 

19. Special hardships. I ask the court to consider the following special financial circumstances

 

 

 

(attach documentation of any item listed here, including court orders):

Amount per month

For how many months?

a. Extraordinary health expenses not included in 18b

$

 

 

 

 

 

 

b. Major losses not covered by insurance (examples: fire, theft, other

 

 

 

 

 

 

 

insured loss)

$

 

 

 

 

 

 

c. (1) Expenses for my minor children who are from other relationships and

 

 

 

 

 

 

 

are living with me

$

 

 

 

 

 

 

(2) Names and ages of those children (specify):

(3) Child support I receive for those children

$

The expenses listed in a, b, and c create an extreme financial hardship because (explain):

20.Other information I want the court to know concerning support in my case (specify):

FL-150 [Rev. January 1, 2007]

INCOME AND EXPENSE DECLARATION

Page 4 of 4

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