Work incentives in the table below are light red.
STEP 1  
Unearned Income 
$________  
Subtract General Exclusion 
– $20.00  
Equals Countable Unearned Income 
= $________  
STEP 2  
Earned Income (Gross Wages)  $______  
Subtract Student Earned Income Exclusion  – $ _____ _  
Equals New Countable Earned Income 
= $_______  
Subtract Earned Income Exclusion (subtract an additional $20 if GE was not used in Step 1)  – $ 65.00  
Equals New Countable Earned Income 
= $_______ 

Subtract Impairment Related Work Expense  – $ _____ _  
Equals New Countable Earned Income 
= $_______ 

Divide by 2  รท 2  
Division answer  = $________  
Subtract Division answer from New Countable Earned Income  – $________  
Equals New Countable Earned Income 
= $_______ 

Subtract Blind Work Expense (if blind)  – $ _____ _  
Equals New Countable Earned Income 
= $_______ 

STEP 3  
Total Countable Unearned Income
(from Step 1) 
$_______  
Plus Total New Countable Earned Income (from Step 3) 
+ $_______  
Equals New Countable Earned and Unearned Income 
= $_______ 

STEP 4  
Total New Countable Earned and Unearned Income (from Step 3)  $_______  
Subtract PASS Plan (if approved)  – $ _____ _  
Equals Newest Total Countable Income 
= $_______ 

STEP 5  
SSI FBR (includes any State Supplement)  $________  
Subtract Total Countable Income (from Step 4)  – $________  
Equals New Adjusted SSI Payment 
= $_______ 