Fillable REAL AND PERSONAL PROPERTYSupplement to Medi-Cal Mail-in Application (Department of Health Care Services)

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REAL AND PERSONAL PROPERTYSupplement to Medi-Cal Mail-in Application (Department of Health Care Services)

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The REAL AND PERSONAL PROPERTYSupplement to Medi-Cal Mail-in Application (Department of Health Care Services) form is 2 pages long and contains:

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  • 88 check-boxes
  • 100 other fields

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State of California—Health and Human Services Agency Department of Health Care Services
REAL AND PERSONAL PROPERTY—Supplement to Medi-Cal Mail-in Application
Applicant’s name: __________________________________________________________________ Social security number:____________________________________
First Middle Last
Please fill in the following. You can use additional sheets of paper if more space is needed.
SECTION 1: Financial Institution Accounts—Check the box(es) next to the types of accounts you have.
Banks, Savings/Loans, Credit Union Deferred Compensation Certificate of Deposit (CD) Trust Fund(s)
Savings or Checking Accounts Annuity Money Market Mutual Funds
Retirement Account, IRA, KEOGH Stocks Bonds Other
Fill in the following:
Owner: ________________________________________________________ Owner:______________________________________________________
Account number:__________________ Current value:_________________ Account number: ________________ Current value:________________
Name of financial institution: ________________________________________ Name of financial institution: _____________________________________
Address: _______________________________________________________ Address: ____________________________________________________
Cash or uncashed checks:
Name on the check: ______________________________________________ Amount:_____________________________________________________
SECTION 2: Real Property/Notes, Mortgages, Deeds of Trust, Sales Contracts
Home (whether you live in it or not), other houses, apartments, ranch, land, buildings, mobile homes, or life estates in or outside of the U.S. or the
State of California:
Address or legal description of property: __________________________
__________________________________________________________
Name of owner:______________________________________________
Does anyone live there now? Yes No
How long have they lived there?_________________________________
Name of person living there:____________________________________
Relationship to you: __________________________________________
If you do not live there now, do you want to return to that property to live
some day? Yes No
(You must notify the county within 10 days of any change in plans for living
at the property.)
Is the property currently listed for sale? Yes No
Full value of property (from tax statement): $ _______________________
Amount owed: $ _____________________________________________
Rent collected each month from the property: $_____________________
SECTION 3: Business—(Check each item “Yes” or “No.”)
Expenses on property:
Interest $ _______________ Yearly Monthly
Taxes and assessments $ _______________ Yearly Monthly
Utilities $ _______________ Yearly Monthly
Insurance $ _______________ Yearly Monthly
Upkeep and repairs $ _______________ Yearly Monthly
If you/family member own a life estate property, please fill in the following:
Address: ____________________________________________________
Do you/family member have an income interest in a life estate?
Yes No
Is the life estate producing/giving income? Yes No
Mortgages, promissory notes, deeds of trust, sales contracts:
Held in whose name: __________________________________________
Value/balance: _______________________________________________
Business/Self-employment checking/savings account or cash: Yes No
Business equipment, vehicles, tools, inventory, or materials (including livestock, or poultry not for personal use): Yes No
Type of equipment: _________________________________________________ Name on property: ______________________________________________
Description of item: _________________________________________________ Estimated value: $ _________________ Amount owed:$ ______________
Business real property, buildings, leases, licenses: Yes No
Description: _______________________________________________________ Name on property: ______________________________________________
Estimated value: $ _________________________________________________ Amount owed: $________________________________________________
FOR COUNTY
USE ONLY
Case Name:______
_
_______________
Case Number:
_
_______________
Worker Number:
_
_______________
Date:
_
_______________
Verification (List):
Verification of Income
and Expenses (List):
Verification (List):
A
ppraisal Provided:
Yes No
Business or Self-
employment Verified:
Yes No
Page 1 of 3
MC 322 (05/07)
SECTION 4: Vehicles/Recreational Vehicles
A. List all cars, trucks, motorcycles, airplanes, snowmobiles, or off-road vehicles (even if not running) owned by you or your family. If none, write “none.
Listed for Sale? Used for Business?
Make and Model Year Class (Registration) Owner Amount Owed Yes No Yes No
FOR COUNTY
USE ONLY
List Verification/
Estimates of Value/
Encumbrance
List Verification/
Estimates of Value/
Encumbrance
A
ppraisal Provided:
Yes No
LTC Insurance Benefit
Summary Provided:
Yes No
Transfer or Receiving
NF Level of Care?
Yes No
See MC 176 PI
B. List any boats, campers (do not include trucks), motor homes, or trailers which are not used as a home and are not taxed as real property by the county.
Listed for Sale? Used for Business?
Make and Model Year Class (Registration) Owner Amount Owed Yes No Yes No
If you do not agree with the value DMV gives your vehicle(s) listed above in A and B, you may get another estimate of the value from a qualified professional.
SECTION 5: Other—Do you/family member own:
Jewelry worth more than $100 (not wedding/engagement rings or heirloom): Yes No
Listed for sale? Yes No Value: $_______________ Amount owed: $ _______________ Who owns: ____________________________
Household goods or any personal items valued at more than $500 per item (musical instruments, PC, etc.): Yes No
Value: $ _____________ Description: __________________________________________________________ Jointly owned Separately owned
Mineral rights or mining claims (oil, coal, etc.): Yes No
Is either listed for sale? Yes No Description: ______________________________________ Who owns: ____________________________
Current value: $ _____________ Amount owed: $ _____________ Location: ______________________________________________________________
Burial trusts or contracts, insurance, designated burial funds/money for cemetery plots, caskets, or other burial items: Yes No
Is it for use of immediate family? Yes No
Description: ______________________________________________________ Who owns:_______________________ Current value: $ _____________
Amount owed: $ _____________ Location: ______________________________________________________________ Purchase price: $ ____________
Purchased for whom: ________________________________________________ Account number: _______________________________________________
Life insurance: Yes No
Enter how many policies owned: ______________ If more than one, use additional sheet of paper.
Insurance company:____________________________________________ Person insured:__________________ Policy owned by: __________________
Face value: $ _______________ Policy number:____________________ Date policy issued: _______________ Current cash value: $_______________
Long-term care insurance: Yes No
Name of insurance company: _____________________________________________________________________ Policy number:____________________
Amount of benefits paid by the insurance company to date: $ ________________ Name on policy: ______________________________________________
Other accounts/items: Yes No
Name on account/item: ______________________________________________ Value: $ ____________________________________________________
SECTION 6: Transfer (Check “Yes” or “No.”)
Has anyone closed, given away, transferred, sold, or traded any money, vehicles, or other property like those listed above in the last 30 months? Yes No
If yes, complete the following: Item: _____________________________________________________________________ Date: ______________________
Transferred Sold Traded Closed Given away
I declare under penalty of perjury under the laws of the State of California that the answers I have given are correct and true to the best of my knowledge.
Applicant’s signature Date
Page 2 of 3
MC 322 (05/07)
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.
Page 3 of 3
MC 322 (05/07)
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REAL AND PERSONAL PROPERTYSupplement to Medi-Cal Mail-in Application (Department of Health Care Services)

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Completed 30 July 2020

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