Public Health Division
HIV Community Services Program /Benefit Planning Tool — Guide and Instructions
Client name: / Client number:First calculate the projected wage for the anticipated job.
Hours worked per month / multiplied by hourly wage / = / $0.00
Income / Current / Impacted by earned income? (yes/no) / Impact of earned income /
Cash benefit type: / ChooseYesNo
Earned income: / ChooseYesNo
Total of
cash income: / $0.00
SNAP[1] amount: / ChooseYesNo
Total income: / $0.00
Expense / Current / Impacted by earned income? (yes/no) / Impact of earned income /
Housing: / ChooseYesNo
Healthcare benefit: / ChooseYesNo
Childcare cost: / ChooseYesNo
Total expense: / $0.00
Total net income: / $0.00
What is the change in monthly income with employment?
What additional work incentives will your client be eligible for?
Detail income /
Income / Current / Impacted by earned income? (yes/no) / Impact of earned income /
Cash benefit type — List benefit type
such as SSI, SSDI or TANF: / List dollar amount received each month / Yes — cash amount is reduced by earned income and formula
No — no impact / Enter new amount of cash benefit based on formula;
SSI — amount is reduced one
dollar for every two earned;
first $85 is exempt
SSDI — no reduction if earnings remain under
SGA — ($1,010 for 2012)
Earned income: / If working, enter total monthly gross earnings including hourly wage and hours
per week / N/A / Enter anticipated total monthly gross earnings including hourly wage and projected hours per week
Total of
cash income: / Add columns above / N/A / Add columns above
SNAP[2] amount: / Enter current SNAP grant amount / Yes — SNAP amount
is reduced by
earned income
No — no impact / Enter in amount of SNAP award
Total income: / Add total cash income and SNAP amount / Add total cash income and SNAP amount
Expense / Current / Impacted by earned income? (yes/no) / Impact of earned income /
Housing — State voucher type or program for subsidized rent: / Enter amount of rent payment / Yes — impacted by earned income
No — no impact / To determine adjusted amount contact:
Local Public Housing Authority (PHA) rent specialist or
Supported Housing Program rent specialist/calculator
Healthcare benefit: / List out of pocket cost if applicable / Yes — impacted by earned income
No — no impact / List out of pocket cost if applicable
Childcare cost: / List out of pocket childcare costs/
co-pay / Yes — impacted by earned income
No — no impact / List out of pocket childcare costs/co-pay
Total expense (Housing, healthcare childcare): / Add housing, healthcare and childcare costs / Add housing, healthcare and childcare costs
Total net income: / Subtract expenses from income / Subtract expenses from income
What is the change in monthly income with employment?
(Consider the difference between income with employment and income without employment.)
What additional work incentives will the client be eligible for?
(Consider benefits that come with having a job — refer to resources.)
Client: / Client number: / OHA 8486 (10/14)
[1] Supplemental Nutrition Assistance Program (SNAP)
[2] Supplemental Nutrition Assistance Program (SNAP)