State of California—Health and Human Services Agency Department of Health Care Services
Case name: _________________________________________
Worker’s name: ______________________________________
Worker’s telephone number: ____________________________
PROPERTY SUPPLEMENT
STOP: If you are applying for no-cost Medi-Cal only for children under age 19 and/or pregnant
women applying only for pregnancy-related services, you do not need to complete this form. You
may be contacted later if necessary.
GO: If you are applying for full-coverage Medi-Cal for a family including adults, please complete this
form and be sure to list all your property. The county worker will determine which properties are
important to your application. If you have any questions, please contact your worker. Note: Owning
a home does not make you ineligible for Medi-Cal.
Mark the box under YES or NO for each item held in the name of, or held for the benefit of any family
member in the home. Please follow the instruction below each question.
YES NO ITEM
1. Shares of stock or mutual funds.
If yes, please provide a copy of the stock or mutual fund certificates indicating the number of
shares.
2. Individual Retirement Accounts (IRAs), Keoghs, or work-related pension funds.
If yes, please provide the most recent statements from your employer, financial institution, or
brokerage indicating the amount of principal and interest you are receiving or the cash value
(after penalties for early withdrawal).
3. Annuities, burial trusts, burial contracts or burial insurance, trusts or agreements
where money or property is held for the benefit of any family member in the
home, blocked accounts, court-ordered settlements, judgments, orders for
support, prenuptial and post-nuptial agreements, promissory notes, mortgages,
deeds of trust, etc.
If yes, please provide copies of the policies, contracts, trusts, purchase agreements, court orders,
account documents showing investments and distributions.
4. Business accounts and property.
If yes, please provide tax returns, invoices, receipts, licenses, profit and loss statements, etc.
5. House, condominium, ranch, land, mobile home, or life estate that is your home
that you live in, or that is your former home and is lived in by your spouse, child
under 21, disabled son or daughter, dependent relative, or a sibling who lived in
the property continuously and provided care for one year which enabled you to
remain in the home rather than a nursing facility.
If yes, please list address of property here: ___________________________________________
No verification is required.
6. If you own a home or former home and you are absent for any reason (including
admission into long-term care) but intend to return home someday, please
indicate below. NOTE: The word “intend” means “desire or wish” to return home
even though you may not be physically or mentally able to do so.
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MC 210 PS (05/07)
