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Adjusted Gross Earned Income B. MONTHLY UNEARNED INCOME 4. OASDI-RR 5. Other 7. Gross Unearned Income C. 5 Rev. 04-15 From Through From Through A. MONTHLY EARNED INCOME 1. Gross Income 2. IRWE/BWE Dependent Care Exp 3. FINAL COMPUTATION 8. Total Income 3 7 9. MS Disregard 10. Allocated Income/Child Support 11. Countable Income 12. Protected Income or Poverty Level Standard 17. Total Spenddown 18. Medical Insurance and Other 19. Client Obligation or Adjusted Spenddown x - Approved-Suspended...
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