DRS-314 4/2017 Statement of Financial and Economic Status Name of IL Client/Parent/Guardian: ________________________________ Family Unit - Self____ Spouse _____ Dependents ______ Total _____ SECTION 1. Yearly Income and Expenses - $_________ - $________ $ ________ - = Yearly Income Minus 185% of Poverty Minus Extenuating Costs Use chart A Level Use chart B Use chart C – $ -____ Available Dollars SECTION 2. Income Producing Real Property _____ $__________ $ - $75,000 - = Minus Indebtedness Real Property Minus Allowable Equity ______ $ Available Dollars SECTION 3. Cash, Bonds, Securities, & Investment Note: All savings MUST be considered, even if is a penalty for early withdrawal. (EXCEPTION: Irretrievable trusts) $_______ $3,500 $ - - = Deduct Deduction for Total Cash, Bonds, $250 for spouse and each self Securities & Investment dependent child $__________ Available Dollars SECTION 4. Resource Available for the HMAD Program - Total the Available Dollars from SECTIONS 1, 2, and 3 that are greater than $0.00. Negative dollars from one section $__________ can not decrease the dollars from another section. The total available dollars must be applied to the HMAD program. I declare and affirm under the penalties of perjury that the foregoing is true and correct to the best of my knowledge and ability.
DRS-314 4/2017 Statement of Financial and Economic Status Name of IL Client/Parent/Guardian: ________________________________ Family Unit - Self____ Spouse _____ Dependents ______ Total _____ SECTION 1. Yearly Income and Expenses - $_________ Yearly Income Use chart A - $________ Minus 185% of Poverty Level – Use chart B - $ ________ = Minus Extenuating Costs Use chart C $ -____ Available Dollars SECTION 2. Income Producing Real Property $ _____ Real Property - $__________ Minus Indebtedness - $75,000 = Minus Allowable Equity $ ______ Available Dollars SECTION 3. Cash, Bonds, Securities, & Investment Note: All savings MUST be considered, even if is a penalty for early withdrawal. (EXCEPTION: Irretrievable trusts) $_______ Total Cash, Bonds, Securities & Investment - $3,500 Deduction for self - $ = Deduct $250 for spouse and each dependent child $__________ Available Dollars SECTION 4. Resource Available for the HMAD Program - Total the Available Dollars from SECTIONS 1, 2, and 3 that are greater than $0.00. Negative dollars from one section can not decrease the dollars from another section. $__________ The total available dollars must be applied to the HMAD program. I declare and affirm under the penalties of perjury that the foregoing is true and correct to the best of my knowledge and ability.