Fillable Printable Declaration and Assessment of Assets - Missouri
Fillable Printable Declaration and Assessment of Assets - Missouri
Declaration and Assessment of Assets - Missouri
MISSOURI DEPARTMENT OF SOCIAL SERVICES
FAMILY SUPPORT DIVISION
DECLARATION AND ASSESSMENT OF ASSETS
IDENTIFYING INFORMATION
PAGE 1 OF 3
INSTITUTIONALIZED
DCN NAME SOCIAL SECURITY NUMBER
SPOUSE
TELEPHONE NUMBER ADDRESS (STREET, CITY, STATE, ZIP CODE) RACE SEX BIRTHDATE
COMMUNITY
DCN NAME SOCIAL SECURITY NUMBER
SPOUSE
TELEPHONE NUMBER ADDRESS (STREET, CITY, STATE, ZIP CODE) RACE SEX BIRTHDATE
DATE ASSESSMENT REQUESTED DATE INSTITUTIONALIZED VENDOR NAME
COUNTY USE ONLY
OTHER INSTITUTION NAME AND ADDRESS VENDOR NUMBER LIKELY TO REMAIN
INSTITUTIONALIZED YES NO
ASSESSMENT
TOTAL NON-EXEMPT ASSETS SPOUSAL SHARE DATE ASSESSMENT COMPLETED REASON INACTIVE DATE LEFT INSTITUTION
DECISION
4
$$
TELEPHONE NUMBER COUNTY NO. ELIG. SPEC. NO. LOAD NO. SUPERVISOR NUMBER
EX-
EQUITY HOW VERIFIED
INCLUDE ALL THE REAL AND 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.
YES NO
IN WHOSE NAME LOCATION VALUE
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 SPOUSE PERMANENT IM-78 (6-08)
11
11
COUNTY NAME AND ADDRESS
DECLARATION OF ASSETS
DECLARATION AND ASSESSMENT OF ASSETS (CONTINUED) PAGE 2 OF 3
INSTITUTIONALIZED SPOUSE NAME DCN
COUNTY USE ONLY
E. Stocks
YES NO
IN WHOSE NAME LOCATION VALUE
EX-
EMPT
EQUITY HOW 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:
LOCATION VALUE DEBT
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 mach nery
G. Farm grain and produce
H. Farm livestock
I. Property Claims in Probate Court
J. Burial Plot(s)
the (list):K. O r
MO 886-2524 (6-08) DISTRIBUTION: WHITE - FSD CANARY - INSTITUTIONALIZED SPOUSE PINK - COMMUNITY SPOUSE PERMANENT IM-78 (6-08)
DECLARATION AND ASSESSMENT OF ASSETS (CONTINUED) PAGE 3 OF 3
INSTITUTIONALIZED SPOUSE NAME DCN
COUNTY USE ONLY
L. List any vehicles you or your spouse own or are buying (Include cars, trucks, vans, motorcycles, boats, recreational vehicles,
EX-
EQUITY HOW VERIFIED
tractors, others).
EMPT
MAKE MODEL YEAR OWNER VALUE DEBT HOW IS VEHICLE USED
3. I/WE ARE BUYING OR OWN REAL ESTATE YES NO IF YES, LIST BELOW
WHO HOLDS LOAN WHOSE NAME
HOW IS IT
LIST KIND AND LOCATION
CURRENT AMOUNT
MORTGAGE? NUMBER ON DEED
USED?
VALUE OWED
HOME/RENTAL
4. I/WE HAVE LIFE INSURANCE, PREPAID BURIAL PLANS OR BURIAL FUNDS. YES NO IF YES, LIST BELOW
PERSON INSURED COMPANY NAME POLICY NUMBER
Spousal share is the amount of non-exempt assets that may be disregarded in initial eligibility determinations for
TOTAL NON-EXEMPT ASSETS SPOUSAL SHARE
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 SPOUSE DATE SIGNATURE OF COMMUNITY SPOUSE DATE
44
WITNESS DATE WITNESS DATE ELIGIBILITY SPECIALIST SIGNATURE DATE
4
WITNESS DATE WITNESS DATE SUPERVISOR SIGNATURE DATE
4
THE ASSESSMENT WAS NOT COMPLETED BECAUSE
MO 886-2524 (6-08) DISTRIBUTION: WHITE - FSD CANARY - INSTITUTIONALIZED SPOUSE PINK - COMMUNITY SPOUSE PERMANENT IM-78 (6-08)
