Services Big Sky Senior Services Senior Companion Program Income Review Form

In order to receive a stipend, an AmeriCorps Seniors volunteer in FGP or SCP must be at least 55 years of age and cannot have an annual income from all sources, after deducting allowable medical expenses, which exceeds the program's income eligibility guideline for the state in which he or she resides. Annual income is required to be counted for the past 12 months for volunteers currently serving and estimated for the upcoming 12 months for new volunteers.

Widow(er)Single In all categories below list all sources of income for the volunteer applicant and spouse, if living in same residence.

sources of Applicant andVolunteer'sTotal Monthly Spouse's Spouse, if living in sameMonthlyMonthlyIncome IncomeIncome residence

Interest / Dividends Other: see back for list of other countable income

Allowable deductions for medical expenses, if any. Please note up to 50% of the maximized qualifying amount can be deducted. See attached for examples of allowable medical deductions. Health Insurance Premiums per month Prescription Drugs per month Doctor visits/medical bills per month per year Other allowable medical costs per month per year (See Attached) Total per monthTotal per year

I certify that the information furnished above is correct and understand that falsification of information may result in my being deemed ineligible to receive a stipend as an AmeriCorps Seniors volunteer in FGP/SCP. I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 1001 of Title 18, U.S.C.

Big Sky Senior Services Senior Companion Program Income Review Form

Minus total allowable medical expense deduction: Equals Total Annual Qualifying Income:

Services Big Sky Senior Services Senior Companion Program Income Review Form

What is considered income for determining volunteer eligibility? According to Section 2551.44 of the [AmeriCorps Seniors] 2551.44 SCP Regulations: (a) For determining eligibility, "income" refers to total cash or in-kind receipts before taxes from all sources including: (1) Money, wages, and salaries before any deduction; (2) Receipts from self-employment or from a farm or business after deductions for business or farm expenses; (3) Social Security, Unemployment or Workers Compensation, strike benefits, training stipends, alimony, and military family allotments, or other regular support from an absent family member or someone not living in the household; (4) Government employee pensions, private pensions, regular insurance or annuity payments, and 401(k) or other retirement savings plans; and (5) Income from dividends, interest, net rents, royalties, or income from estates and trusts. (b) For eligibility purposes, income does not refer to the following money receipts: (1) Any assets drawn down as withdrawals from a bank, sale of property, house or car, tax refunds, gifts, one-time insurance payments or compensation from injury; (2) Non-cash income, such as the bonus value of food and fuel produced and consumed on farms and the imputed value of rent from owner-occupied farm or non-farm housing; (3) Regular payments for public assistance including the Supplemental Nutrition Assistance Program (SNAP) (4) Social Security Disability or any type of disability payment; and (5) Food or rent received in lieu of wages.

What are allowable medical expenses that may be deducted from income? According to the [AmeriCorps Seniors] FGP Regulations, 2552.43(c) and SCP Regulations, 2551.43(c): Allowable medical expenses are annual out-of-pocket medical expenses for health insurance premiums, health care services, and medications provided to the applicant, enrollee, or spouse which were not and will not be paid by Medicare, Medicaid, other insurance, or other third party pay or, and which do not exceed 50 percent of the applicable income guideline. Examples of allowable out-of-pocket medical expenses include but are not limited to: Health Insurance Costs: Private insurance, Medicare/Medicaid premiums, co-payments and deductibles, long term care insurance Prescription Drugs: Pharmacy program co-payments and deductibles Medical Bills for Dr. Visits: Included, but not limited to: medical care, dental care, vision care not covered by health insurance Other out-of-pocket Medical expenses: One-time medical expense: equipment, supplies for dentures, hearing aids, eyeglasses, wheelchairs, canes, etc. Over the counter drugs and supplies not covered by health insurance: pain relievers, antacids, hearing aid batteries, vitamins, non-prescription eye glasses.