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Fillable Printable Declaration and Assessment of Assets - Missouri

Fillable Printable Declaration and Assessment of Assets - Missouri

Declaration and Assessment of Assets - Missouri

Declaration and Assessment of Assets - Missouri

MISSOURI DEPARTMENTOF SOCIALSERVICES
FAMILY SUPPORTDIVISION
DECLARATION AND ASSESSMENT OF ASSETS
IDENTIFYING INFORMATION
PAGE 1 OF 3
INSTITUTIONALIZED
DCNNAMESOCIALSECURITY NUMBER
SPOUSE
TELEPHONE NUMBERADDRESS (STREET, CITY, STATE, ZIP CODE)RACESEXBIRTHDATE
COMMUNITY
DCNNAMESOCIALSECURITY NUMBER
SPOUSE
TELEPHONE NUMBERADDRESS (STREET, CITY, STATE, ZIP CODE)RACESEXBIRTHDATE
DATE ASSESSMENT REQUESTEDDATE INSTITUTIONALIZEDVENDOR NAME
COUNTYUSE ONLY
OTHER INSTITUTION NAME AND ADDRESSVENDOR NUMBERLIKELY TO REMAIN
INSTITUTIONALIZED YES NO
ASSESSMENT
TOTAL NON-EXEMPT ASSETSSPOUSALSHAREDATE ASSESSMENT COMPLETEDREASON INACTIVEDATE LEFT INSTITUTION
DECISION
4
$$
TELEPHONE NUMBERCOUNTY NO.ELIG. SPEC. NO.LOAD NO.SUPERVISOR NUMBER
EX-
EQUITYHOW VERIFIED
INCLUDE ALLTHE REALAND PERSONAL PROPERTY OWNED BY THE SPOUSE WHO IS INSTITUTIONALIZED
EMPT
AND THE SPOUSE WHO LIVES AT HOME FOR THE MONTH OF 4
1. I/We have the following cash and securities.
YESNO
IN WHOSE NAMELOCATIONVALUE
A.Checking account/joint checking accounts
Account Numbers:
1)
2)
3)
B.Savings Accounts, Joint Savings Accounts, Christmas
Club Savings, Time Certificates or Deposit in Credit
Union.
Account or Certificate Numbers:
1)
2)
3)
4)
5)
C. Patient accounts at nursing home or other institution.
D. Savings or cash at home, on my person, or being held
by someone else.
MO 886-2524 (6-08)DISTRIBUTION: WHITE - FSD CANARY - INSTITUTIONALIZED SPOUSE PINK- COMMUNITY SPOUSEPERMANENTIM-78 (6-08)
11
11
COUNTY NAME AND ADDRESS
DECLARATION OF ASSETS
DECLARATION AND ASSESSMENT OF ASSETS (CONTINUED)PAGE 2 OF 3
INSTITUTIONALIZED SPOUSE NAMEDCN
COUNTYUSE ONLY
E.Stocks
YESNO
IN WHOSE NAMELOCATIONVALUE
EX-
EMPT
EQUITYHOW VERIFIED
Company and number of shares
1)
2)
3)
F.Bonds or other investments
1)
2)
3)
G.Notes or Mortgages owed to you
(Does any one owe you money?)
H. Trust Funds
I.Property held in Safe Deposit Box Contents
2.I/We have the following personal property:
LOCATIONVALUEDEBT
A.Household Furniture (in use)
B.Household Furniture (not in use)
C. Housetrailer (mobile home)
D. Jewelry (other than wedding and engagement rings,
watches or costume jewelry)
i
E.Business equipment
F.Farm machnery
G.Farm grain and produce
H. Farm livestock
I.Property Claims in Probate Court
J.Burial Plot(s)
the (list):K.Or
MO 886-2524 (6-08)DISTRIBUTION: WHITE - FSD CANARY - INSTITUTIONALIZED SPOUSE PINK- COMMUNITY SPOUSEPERMANENTIM-78 (6-08)
DECLARATION AND ASSESSMENT OF ASSETS (CONTINUED)PAGE 3 OF 3
INSTITUTIONALIZED SPOUSE NAMEDCN
COUNTYUSE ONLY
L.List any vehicles you or your spouse own or are buying (Include cars, trucks, vans, motorcycles, boats, recreational vehicles,
EX-
EQUITYHOW VERIFIED
tractors, others).
EMPT
MAKEMODELYEAROWNERVALUEDEBTHOW IS VEHICLE USED
3.I/WE ARE BUYING OR OWN REAL ESTATEYES NO IF YES, LIST BELOW
WHO HOLDSLOANWHOSE NAME
HOW IS IT
LIST KIND AND LOCATION
CURRENTAMOUNT
MORTGAGE?NUMBERON DEED
USED?
VALUEOWED
HOME/RENTAL
4.I/WE HAVE LIFE INSURANCE, PREPAID BURIAL PLANS OR BURIALFUNDS.YES NO IF YES, LIST BELOW
PERSON INSUREDCOMPANY NAMEPOLICY NUMBER
Spousal share is the amount of non-exempt assets that may be disregarded in initial eligibility determinations for
TOTAL NON-EXEMPT ASSETSSPOUSALSHARE
nursing care vendor benefits for the institutionalized spouse during this continuous period of institutionalization.
$$
I/we understand that this assessment is valid for this continuous period of institutionalization in a MO HealthNet certified bed or hospital.
I/we understand that we do not have the right to appeal the determination of the value of non-exempt assets or the spousal share until such time as
the institutionalized spouse applies for nursing care vendor benefits.
I/we understand that we MUST immediately notify the Family Support Division when
the institutionalized spouse is discharged from the nursing home or hospital
either spouse dies
we become divorced
the spouse who lives at home goes into a nursing home or hospital for 30 days or longer
I/we the above named requestor(s) or representative(s) do solemnly swear that I/we fully and clearly understand the questions set forth and that I/we
have truthfully and to the best of my/our ability given the answer to each question.
SIGNATURE OF INSTITUTIONALIZED SPOUSEDATESIGNATURE OF COMMUNITY SPOUSEDATE
44
WITNESSDATEWITNESSDATEELIGIBILITY SPECIALIST SIGNATUREDATE
4
WITNESSDATEWITNESSDATESUPERVISOR SIGNATUREDATE
4
THE ASSESSMENT WAS NOT COMPLETED BECAUSE
MO 886-2524 (6-08)DISTRIBUTION: WHITE - FSD CANARY - INSTITUTIONALIZED SPOUSE PINK- COMMUNITY SPOUSEPERMANENTIM-78 (6-08)
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