Supplementary Expenses Worksheet
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Total expenses that are incurred each month by, or for, the person with the disability.
Government Benefits $____________
(Total income from all government resources excluding family assistance. Do not include basic medical/dental care that is paid by Medicaid, Medicare, MediCal, or private medical/dental insurance.)
$______ Housing (Description: _________________)
________ Rent/Month
________ Utilities
________ Maintenance
________ Cleaning Home
________ Laundry Costs
________ Other
$______ Care Assistance
________ Live-In
________ Respite
________ Custodial
________ Other
$______ Personal Needs
________ Haircuts, Beauty Shop
________ Telephone (Basic, TDD, etc.)
________ Books, Magazines, etc.
________ Allowances
________ Other
$______ Employment
________ Transportation
________ Workshop Fees
________ Attendant
________ Training
________ Other
$______ Education
________ Transporation
________ Fees
________ Books
________ Other
$______ Special Equipment
________ Environmental Control
________ Elevator
________ Repair of Equipment
________ Computer
________ Audiobooks
________ Ramp
________ Guide/Hearing Dog
________ Technical Instruction
________ Hearing Aids
________ Wheelchair
________ Other
$______ Medical/Dental Care
________ General Medical/Dental Visits
________ Therapy
________ Nursing Services
________ Meals of Attendants
________ Evaluations
________ Transportation
________ Other
$______ Social/Recreational
________ Sports
________ Special Olympics
________ Spectator Sports
________ Vacations – Friends/Relatives
________ TV/Rental
________ Camps
________ Transportation Costs
________ Other
$______ Clothing – Extra
$______ Food
________ Meals, Snacks – Home
________ Outside of Home
________ Special Foods/Gastric Tube
________ Other
$______ Automobile/Van
________ Payments
________ Gas/Oil/Maintenance
________ Other
$______ Insurance
________ Medical/Dental
________ Burial
________ Van/Automobile
________ Housing/Rental
________ Other
$______ Miscellaneous
________ Other
________ Other
________ Other
Total Expenses $______
Less Government Benefits $______
Supplementary Expenses $______