Fillable Form 1.: PROPERTY ASSESSMENT STATEMENT OF FACTS 2. (Department of Health Care Services)

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Form 1.: PROPERTY ASSESSMENT STATEMENT OF FACTS 2. (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health Care Services
PROPERTY ASSESSMENT STATEMENT OF FACTS
1.
Name of applicant or authorized representative by whom assessment is requested Home telephone number
( )
Work telephone number
( )
Home address (number, street) City State ZIP code
Mailing address (if different from above) (number, street, P.O. Box number, etc.) State ZIP code City
2.
Complete for person residing in a nursing home or medical institution receiving a nursing facility level of care.
Name (first, middle, last) Social security number Birth date (mm/dd/yy) Sex
Male Female
Home address (number, street) City State ZIP code
Previous address (number, street) State ZIP code
Date entered nursing facility Do you plan to return home?
Yes No
If yes, when?
City
Marital status
Married Never married Separated Divorced Common law Widow/er
3.
Complete for “at home” (community) spouse.
Name (first, middle, last) Social security number Birth date (mm/dd/yy) Sex
Male Female
Home address (number, street) City State ZIP code
COUNTY USE ONLY
4.
A. Do you or any family member have any of the property/resources listed below? Check
() each item either “yes” or “no.”
Include all resources owned, used, controlled, or held jointly with or for another
person(s).
Include resources on which persons listed in 2 and 3 are named (even for
convenience only).
The county will determine whether or not these resources count.
Trust fund not court ordered
Court petitioned
Date: __________________
YES NO YES NO Resources verified
Cash (on hand or elsewhere) Money market accounts
Explain how:
Uncashed check (on hand or
elsewhere)
Trust funds (whether or not available)
Savings accounts (children’s and
adult’s)
Notes, mortgages, trusts, deeds,
contract of sales, etc.
Checking accounts (whether or not they
are used)
IRA or KEOGH plans
Credit union accounts
Retirement funds (such as PERS)
available if you stop work
Stocks or bonds Employee deferred compensation plans
Certificates of deposit
Other (specify type)
If yes to any of the above, complete the section below.
Type of Resource Owner Account Number Name and Address of Bank Current Value
$
$
$
$
MC 210 PA (05/07) Page 1 of 4
COUNTY USE ONLY
B. Have you or any member of your family closed or transferred a bank
account during the past 30 months (2½ years)?
If yes, complete information below:
Yes No
Type of Account Date Account(s) Closed or Transferred
Balance at Time of
Closing or Transfer
LTC only:
Adequate consideration
Spenddown
5.
Do you or any family member own life insurance? Yes No
1. Person Insured
Insurance Company
2. Policy Owned By
Face Value Policy Number
Date Policy
Issued
Current Cash
Value
1.
A. 2. $ $
Exempt
Yes No $ __________
1.
B. 2. $ $
Exempt
Yes No $ __________
1.
C. 2. $ $
6.
Do you or any family member own a burial plot, vault, or crypt?
For use of immediate family?
If yes, complete the following:
Yes No
Yes No
Exempt Yes No $ __________
Total CSV $___________
Description ned by
Current value
$
Amount owed
$
Location
7.
Do you or any family member own a burial reserve or trust?
If yes, complete the following:
Yes No
Revocable
Irrevocable
Purchase price
$
Amount owed
$
Purchase price
$
Amount owed
$
Current value: $ ____________
FOR whom purchased FROM whom purchased
8.
List all vehicle(s) (even if not running) owned by you or your family.
List exempt vehicle:
Class Amount
Used for
Transportation
Name and Model Year
(Registration)
Owner wed Yes No
Verification of nonexempt vehicles
9.
Do you or any family member own boats, campers (do not include trucks),
motor homes, mobile homes, or trailers that are not used as home and are
not taxed as real property by the county?
Yes No
Verification of personal property
Class Purchase
Only Mode of
Transportation
Description Year
(Registration)
Owner e Yes No
$
$
$
$
$
NOTE: If you think the value of the items above based on Department of Motor Vehicles registration tables will be too
high, you may provide three appraisals of the actual value, and the average will be used.
CSV
CSV
CSV
Ow
If none, state “None.”
O
Pric
MC 210 PA (05/07) Page 2 of 4
COUNTY USE ONLY
10.
Do you or any family member own business equipment, vehicles, tools,
inventory, or materials (including livestock or poultry not for personal use)?
If yes, list:
Yes No
Description Estimated Value Amount Owed
$
$
$
11.
Are you or any family member buying or the owner of any land and/or
buildings in which you do not now live? e sure to include property in
any state or country and all land you own, have title to, or share title in.)
For example: lots, houses, trailers, apartments, mobile homes which are
taxed as real property by the county, etc.
If yes:
Yes No
Verification of “Good Cause” for utilization of
property
Verification of income and expenses (list):
Address of other property (number, street) City State ZIP code
Description of property Name of owner
Does anyone live there now?
Yes No
If yes, who lives there now? What is their relation to you? How long have they
lived there?
Do you plan to return to that property to live?
(If you later change your mind, you must notify the county within 10 days.)
Yes No
Is the property currently listed for sale?
Yes No
Full value (from tax
statement)
$
Amount owed
$
Rent collected each month
$
Expenses on Property
Interest
Yearly
$
Monthly
Insurance
Yearly
$
Monthly
Utilities
Yearly
$
Monthly
Taxes and assessments
Yearly
$
Monthly
Upkeep and repairs
Yearly
$
Monthly
12.
Do you or any family member have a Life Estate interest (Right to the Use
Of) in any property?
If yes, what is the address?
Yes No
Revocable
Irrevocable
Address (number, street) City State ZIP code
Do you or any family member have an income interest in a Life Estate?
If yes, is the Life Estate producing income?
Yes No
Yes No
How much received?
$
How often?
13.
Have you or any family member transferred, sold, or given away any
property (including money) during the past 30 months (2½ years)?
If yes, list:
Yes No
LTC ONLY:
Adequate consideration
Spenddown
Description of Item
Date of Sale,
Transfer, or Gift Value Amount Received
$ $
$ $
14.
Have you eceived money from ance ourt settlements,
inheritance, lottery, or back pay in the past 30 months (2½ years)?
If yes, list:
Yes No
LTC ONLY:
Adequate consideration
Spenddown
Source Date Received Amount
$
$
$
15.
A. Have you or any family member encumbered property or made a
payment for health care service you received or will receive during a
period for which you are asking for Medi-Cal benefits?
Yes No
Payment or lien used to bring property within
property limits
Yes No
B. Has a lien been recorded against your property or the property of a
family member as security for health care services received or to be
received during a period for which you are asking for Medi-Cal benefits?
C. If yes to A or B, complete below:
Yes No
If yes:
Notice to provider
Amount of payment/encumbrance or lien
$
Encumbrance or payment made to or
lien recorded by
Date and type of medical care received
or to be received
$
$
$
(B
r insur cor
MC 210 PA (05/07) Page 3 of 4
PRIVACY STATEMENT
• Medi-Cal Confidentiality Notice: The information given in this application is private and confidential under
Welfare and Institutions Code, Section 14100.2. This information will be disclosed only in accordance with
those laws.
• Medi-Cal Privacy Notice
: This information may be shared with federal, state, and local agencies for
purposes of verifying eligibility and for other purposes related to the administration of the Medi-Cal program,
including confirmation with the INS of the immigration status of only those persons seeking full scope Medi-Cal
benefits. (Federal law says the INS cannot use the information for anything else except cases of fraud.)
• Information required by this form is mandatory
, with the exception of ethnicity information, and any other
item marked voluntary or optional.
MC 210 PA (05/07) Page 4 of 4
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Form 1.: PROPERTY ASSESSMENT STATEMENT OF FACTS 2. (Department of Health Care Services)

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Completed 30 July 2020

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