Fixed Countable Income includes

~Supplemental Security Income

~Social Security Disability Insurance

~Pension

~Widow/Widower's Benefit

~Alimony

~Black Lung Pension

Earned Countable Income Includes:

~Wages

~Active Military Pay

Other Earned Countable Income Includes:

~Seasonal Employment

~Self-Employment

Supplemental Countable Income includes:

~Unemployment

~Utility Assistance

~Workers' Compensation

~Ohio Works First

~Temporary Assistance for Needy Families (TANF)

~Employee Disability Payouts

~Strike Benefits

Other Countable Income includes:

~Cash withdraws from: Individual Retirement Accounts, Annunities, Other Investments

~Lump sum payout from: Estate & Trust statements, Divorce Settlements, Insurance Payouts, Lottery Winnings

~Interest Income

Deductible Income includes:

~Health Insurance Premiums

~Short and Long-Term Disability Premiums

~Prescriptions Plans

~Health Care Spending Accounts

~Medicaid Spend Down (deductibles)

~ Medicare Premiums

~Child Support paid-out, Attorney Fees for Estate or Trust Settlements

~Self-Employment IRS Allowable Business Expenses

~Reimbursement for Work Expenses

Excluded Income includes:

~Agency Orange Pension

~Veterans Affairs, Service Related Disability

~Handicapped Income (i.e. work programs for the blind or disabled)

~Title V Wages (i.e. Senior Employment Programs)

~Volunteers in Service to America Stipend (VISTA)

~Work Allowances (work requitement to receive OWF assistance)

~Income Earned by Dependant Minors

~Tax Refunds/Rebates

~Educations Assistance (grants stipends for tuition/books)

~Stipeds for Foster Care

~Military Allowances for Subsistence

~Ohio Waiver Program (Medicaid benefit for caregiver)

Prevention Retention and Contingency (i.e. emergency services, rental assistance)

~Transportation Allowances for Subsistances

~Proceeds from Reverse Mortgage

~FEMA, Cash Payments

~Title III Disaster Relief Emergency Assistance

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I certify that this statement is true and correct to the best of my knowledge, and I authorize the release of any or all information necessary for verification purposes.