A percentage of the FBR, which is less than 300% % Specify the percentage: A dollar amount which is less than 300%. $ Specify dollar amount: % A percentage of the Federal poverty level Specify percentage: Other standard included under the State Plan Specify: $ If this amount changes, this item will be revised. The following dollar amount Specify dollar amount: The following formula is used to determine the needs allowance: Specify: Other Specify: ii. Allowance for the spouse only (select one): Not Applicable The State provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided: Specify: Specify the amount of the allowance (select one): The following standard under 42 CFR §435.121: Specify: Optional State supplement standard Medically needy income standard $ If this amount changes, this item will be revised. The following dollar amount: Specify dollar amount: The amount is determined using the following formula: Specify: iii. Allowance for the family (select one): Not Applicable (see instructions)
% A percentage of the FBR, which is less than 300% Specify the percentage: $ A dollar amount which is less than 300%. Specify dollar amount: % A percentage of the Federal poverty level Specify percentage: Other standard included under the State Plan Specify: The following dollar amount Specify dollar amount: $ If this amount changes, this item will be revised. The following formula is used to determine the needs allowance: Specify: Other Specify: ii. Allowance for the spouse only (select one): Not Applicable The State provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided: Specify: Specify the amount of the allowance (select one): The following standard under 42 CFR §435.121: Specify: Optional State supplement standard Medically needy income standard The following dollar amount: Specify dollar amount: $ If this amount changes, this item will be revised. The amount is determined using the following formula: Specify: iii. Allowance for the family (select one): Not Applicable (see instructions)
ABI%20Waiver%20Amendment%20-%20Final%20Draft%20for%20Public%20Comment.docx