Branch: Case Number: Program:
Case Name: Worker ID:

Date:     Policy:  Oregon Programs Eligibility Notebook (OPEN)   Explanation:  English   Spanish

Benefits Paid

Net Allotment:
Overpayment Recovery:
Benefit Amount:   (Net Allotment + Overpayment Recovery)

Household Information

Noncitizen Calculation? Yes

Number in Household:
Number of Adults in Benefit Group:
Number of Children in Benefit Group:
Number in Need Group:       Use only if Household includes Ineligible Noncitizens

Allow COI: Yes

Income Information

Reminder: Is this Microenterprise income?

Earned Income - Allow Deduction:     Enter Full Amount - Deduction will be calculated.
Earned Income - No Deduction:
Unearned Income:
Child Support:    Retained By DHS as Current Reimbursement

Adjustment Information

EBT Adjustments:   (Including aged off benefits)
Adjustment for Prior Overpayment:   


      Spanish Form284G (Use only for Non-Citizen Calculation)  DHS 221T