Alaska Division of Vocational Rehabilitation
Financial Participation Assessment Certification
Name:
1. Public Support:
Food Stamps: TANF: SSI/SSDI: Medicaid:
(Skip to 5. Certification, if the individual is eligible for any of the above.)
2. Basic Living Requirement (BLR) Deductions:
Family Deduction (size and geographical differential) 0
Size: 0
Geographic area: 0
Disability Related Expenses - annual estimate
Child support or alimony - annual estimate
Total Deductions 0
3. Resources:
Projected annual gross income (include monthly income from life insurance, trust funds or retirement
accounts or payments for child support/alimony)
Source Months Amount per Month Income
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
Liquid Assets and Amounts
Money Market Funds Permanent Fund Dividend
Cash/Savings/Checking /CDs Workers Compensation
Mutual Funds/Treasury Bills Annual Corporation Dividends
Preferred and Common Stock Other
Total Resources 0
4. Available Resources (Total Resources - BLR Deductions) 0
5. Certification
I hereby certify that the above is a true statement of my financial resources. I further agree to notify
DVR if there are any changes in my circumstances. I understand failure to report information
accurately could result in my case being closed. I also understand this information will be re-
evaluated annually or if my financial circumstances change or at my request. This information will be
kept confidential and is used only for the purpose of determining the potential financial participation
in the Alaska DVR program.
Participant or Representative DVR Representative
Date Date
Revised: 4/28/2010
370cb4db-7ca7-4fcf-927d-1252ca3249f5.xls
Alaska Division of Vocational Rehabilitation
Financial Participation Assessment Certification
Name:
1. Public Support:
Food Stamps: TANF: SSI/SSDI: Medicaid:
(Skip to 5. Certification, if the individual is eligible for any of the above.)
2. Basic Living Requirement (BLR) Deductions:
Family Deduction (size and geographical differential)
Size:
Geographic area:
Disability Related Expenses - annual estimate
Child support or alimony - annual estimate
Total Deductions
3. Resources:
Projected annual gross income (include monthly income from life insurance, trust funds or retirement
accounts or payments for child support/alimony)
Source Months Amount per Month Income
Liquid Assets and Amounts
Money Market Funds Permanent Fund Dividend
Cash/Savings/Checking /CDs Workers Compensation
Mutual Funds/Treasury Bills Annual Corporation Dividends
Preferred and Common Stock Other
Total Resources
4. Available Resources (Total Resources - BLR Deductions)
5. Certificationthat the above is a true statement of my financial resources. I further agree to notify
I hereby certify
DVR if there are any changes in my circumstances. I understand failure to report information
Participant or Representative DVR Representative
Date Date
Tables for Calculating the Basic Living Requirement (BLR) Deductions for the Financial
Participation Assessment Certificate
Deductions Based upon Family Size and Regional Differential - 2010 Guidelines
DVR uses a base of 250% of poverty guidelines and then adds a regional differential*
Family Size
Locality Code Communities Locality Differential 1 2 3 4 5 6
1 Anchorage, Delta Junction/Tok 1.00 34,000 45,950 57,900 69,850 81,800 93,750
Region, Fairbanks, Glennallen
Region, Kenai Peninsula,
Ketchikan, Mat-Su,
Parks/Elliot/Steese Highways,
Southeast Mid-Size Communities,
Southeast Small Communities
Cordova, Juneau, Kodiak, Sitka,
2 Valdez 1.11 37,740 51,005 64,269 77,534 90,798 104,063
Dillingham, Nome, Roadless
3 Interior 1.37 46,580 62,952 79,323 95,695 112,066 128,438
Barrow, Bethel, Aleutians (other
than Unalaska/Dutch Harbor),
4 Southwest Small Communities 1.50 51,000 68,925 86,850 104,775 122,700 140,625
5 Kotzebue, Unalaska/Dutch Harbor 1.60 54,400 73,520 92,640 111,760 130,880 150,000
Alaska DVR
Differential = Alaska DVR Baseline:
250% of Current Federal Poverty Standard
Current Federal Alaska Poverty Standard Alaska Poverty * 250%
Base Family of 1 13,600 250% $34,000.00
Each Person
beyond 1 4,780 250% $11,950.00
* Regional Differential Source: State of Alaska’s Geographical Differential Study conducted in 2008 by the McDowell Group
Formula for Calculating the BLR
BLR = ((Amount of poverty allowance for single person family + (Number of Dependents * Amount of Personal Poverty
Allowance)) * Geographical Factor) * ADVR Poverty Allowance
This is a fast and easy to use process which does all the calculations for you and prints everything needed for documentation in
This is the preferred method of calculating need.
Here are some simple instructions for using the spreadsheet:
1. The first section of the spreadsheet is the worksheet. The best way to move through the worksheet is by using the TAB key.
2. Start by filling the client's name, family size (remember to count the client) and the area of the state code. The deductions for
3. Fill in any income, liquid assets and any other deductions other than the family deduction.
4. Print. Three pages will be printed: the copy for all to sign and the backup worksheet and table.
5. You do not need to save the spreadsheet with the information once it is printed. I would suggest not saving it as we will clutt
If you do need to save the information for some reason, use the Save As function in the File menu and rename it usi
You will notice as you move through the worksheet that you only have access to those cells that require information. .
Any calculated cells are protected to preserve the integrity of the formulas that sit behind them
The "Table" tab or worksheet are the actual deductions and can be printed for a ahndy reference if you would like.
g needed for documentation in the case file.
heet is by using the TAB key.
tate code. The deductions for the family are calculated for you.
st not saving it as we will clutter up our drives. .
File menu and rename it using the client's name
equire information. .
erence if you would like.