ARIZONA STATE VETERAN HOME
FINANCIAL INFORMATION STATEMENT
The following information is required to process your application for admission to the Arizona State
Veteran Home. if this information is incomplete, it will delay consideration of your application. If
questions are not applicable, please indicate with the abbreviation “N/A”. Information submitted is subject
to verification. The Arizona State Veteran Home reserves the right to request verification of any funds
received by copies of award forms or award letters.
APPLICANT’S NAME__________________________________________DATE____________________
APPLICANT’S SOCIAL SECURITY # _____________________________
SPOUSE’S SOCIAL SECURITY # _______________________________
A. MONTHLY INCOME VETERAN SPOUSE
Social Security Benefits _________ ________
U.S. Civil Service benefits (annuity number) ____________ _________ ________
U.S. Railroad retirement (number) ____________________ _________ ________
Military Retirement _________ ________
V.A. Awards (type) ________________________________ _________ ________
State Retirement _________ ________
Company Retirement _________ ________
Private Retirement _________ ________
Black Lung _________ ________
Benefit _________ ________
SSI/Public Assistance _________ ________
Total Wages _________ ________
Total Dividends _________ ________
Total Interest _________ ________
Other (specify source) _____________________________ _________ ________
TOTAL MONTHLY INCOME FROM ALL SOURCES ________ _______
B. EXPENDITURES
Medicare B Premium (per month) ___________________
ALTCS Share of Cost (per month) ___________________
C. ONE TIME INCOME IN THE PAST 12 MONTHS ________ _______
Type ___________________________________________ _________ ________
Type ___________________________________________ _________ ________
D. NET WORTH (Excluding Home and Auto)
Cash ________________ Bank Account ________________ Savings ________________
CD’s ________________ Millers Trust _________________ Revocable Trust __________
NET WORTH TOTALS _________ ________
E. MEDICAL EXPENSES NOT REIMBURSED LAST YEAR
_________ ________
Signing below certifies that the above information is complete and correct. Authorization is given to
verify any information provided herein.
Signature ______________________________Relationship _________________Date___________
ASVH-P 05-042 (Revised 11/99)
