HAVE YOU, YOUR SPOUSE OR YOUR PARENT(S) APPLIED FOR OR DO YOU EXPECT TO
START RECEIVING INCOME FROM ANY OF THE SOURCES LISTED IN “ITEM 16”?
(IF “YES”, GIVE THE INFORMATION BELOW:)
TYPE OF INCOME
PLACE APPLIED DATE APPLIED DATE EXPECTED
(A.) DO YOU, YOUR SPOUSE OR YOUR PARENT(S) RECEIVE ANY NON-CASH GIFTS OR
CONTRIBUTIONS OF RENT, FOOD, CLOTHING OR OTHER ITEMS OF NEED?
(B.) DO YOU, YOUR SPOUSE OR YOUR PARENT(S) RECEIVE NON-CASH COMPENSATION IN
RETURN FOR WORK?
(IF “YES” TO “(A)” OR “(B)”, GIVE THE INFORMATION BELOW:)
ITEM CONTRIBUTED
FREQUENCY OF
RECEIPT
CASH EQUIVALENT
DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE HEALTH OR HOSPITALIZATION
INSURANCE (INCLUDING PAID BY AN EMPLOYER)?
(IF “YES”, GIVE THE INFORMATION BELOW:)
INSURANCE CARRIER (CHECK APPLICABLE(S))
PERSON(S) INSURED
■■ MEDICARE
(CLAIM NO. )
■■ CHAMPUS
■■ VETERAN’S ADMINISTRATION COVERAGE
■■ KAISER
■■ ROSS—LOOS
■■ BLUE SHIELD
■■ BLUE CROSS
■■ PREPAID HEALTH PLAN
■■ HEALTH MAINTENANCE ORGANIZATION
(SPECIFY: )
■■ OTHER CARRIER
(SPECIFY: )
ITEM NUMBER
ADDITIONAL INFORMATION (ATTACH ADDlTlONAL SHEETS IF NECESSARY)
BE SURE YOU HAVE READ EVERY ITEM AND ANSWERED ALL THE QUESTIONS THAT APPLY TO YOU. READ THE FOLLOWING CAREFULLY BEFORE SIGNING:
I HEREBY STATE BY MY SIGNATURE THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE.
I AGREE TO TELL THE COUNTY DEPARTMENT OF SOCIAL SERVICES WITHIN 10 DAYS IF THERE ARE ANY CHANGES IN MY INCOME, POSSESSIONS. OR EXPENSES, OR IN THE
NUMBER OF PERSONS IN MY HOUSEHOLD, OR IF ANY CHANGE OF ADDRESS. AND I AGREE TO MEET ALL OTHER RESPONSIBILITIES EXPLAINED IN THE “MEDI–CAL
RESPONSIBILITIES CHECKLIST” I HAVE RECEIVED.
I UNDERSTAND THAT I MAY BE ASKED TO PROVE MY STATEMENTS, BUT THAT THE COUNTY IS REQUIRED BY LAW TO KEEP THEM CONFIDENTIAL.
I UNDERSTAND THAT IF I AM DISSATISFIED WITH ANY ACTIONS TAKEN BY THE COUNTY DEPARTMENT OF SOCIAL SERVICES, I HAVE THE RIGHT TO A STATE HEARING.
I UNDERSTAND THAT I MUST DISPOSE OF ANY EXCESS RESOURCES WITHIN A SIX–MONTH PERIOD IN THE CASE OF REAL PROPERTY AND WITHIN THREE MONTHS IN THE
CASE OF PERSONAL PROPERTY AND REPAY ANY OVERPAYMENTS WITH THE PROCEEDS OF THE DISPOSED PROPERTY.
I UNDERSTAND THAT IF I AM ELIGIBLE FOR IHSS SERVICES, I WILL BE PROVIDED A MEDI–CAL CARD AT NO SHARE–OF–COST TO ME IF I PAY THE IHSS SHARE OF COST I AM
OBLIGATED TO PAY.
I UNDERSTAND THAT FEDERAL AND STATE LAW REQUIRE THE RECOVERY OF ALL MEDI-CAL BENEFITS RECEIVED AFTER AGE 55 FROM THE ESTATE OF A MEDI–CAL
BENEFICIARY IF THERE IS NO SURVIVING SPOUSE, MINOR CHILDREN, OR PERMANENTLY AND TOTALLY DISABLED CHILDREN.
SOC 310 VERIFICATION
■■ ELIGIBLE ■■ INELIGIBLE
REASON (IF INELIGIBLE):
SOCIAL SERVICE WORKER:
DATE:
I, THE UNDERSIGNED, DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT.
SIGNATURE OF APPLICANT DATE
SIGNATURE OF WITNESS
(REQUIRED IF APPLICANT
SIGNED BY MARK)
SIGNATURE OF PERSON ACTING FOR APPLICANT
(RELATIONSHIP: PARENT, GUARDIAN, CONSERVATOR)
DATE
SIGNATURE OF PERSON HELPING APPLICANT
COMPLETE FORM
DATE
DATE
Page 4 of 4 pages
FOR COUNTY USE ONLY
EXPECTED INCOME
How Verified:
a. _____________________________
b. _____________________________
c. _____________________________
IN-KIND INCOME
30-775.11
How Verified: ____________________
_______________________________
_______________________________
_______________________________
_______________________________
PREMIUM PAYMENTS
Amount Paid: $ __________________
How often: ______________________
How Verified: ____________________
_______________________________
_______________________________
_______________________________
_______________________________
■■ YES ■■ NO
■■ YES ■■ NO
■■ YES ■■ NO
■■ YES ■■ NO
17.
HAVE YOU, YOUR SPOUSE OR YOUR PARENTS HAD MEDICAL EXPENSES WITHIN THE LAST
3 MONTHS AND WANT MEDI-CAL FOR THOSE EXPENSES?
■■ YES ■■ NO
18.
19.
20.
$
$
21.
