Dhs 1169 Form PDF Details

The Dhs 1169 form is something that tax professionals and other individuals need to be familiar with. This form is used for a variety of purposes, such as estate and gift taxes. It's important to know how to complete the form correctly so that you can avoid any delays or potential penalties. In this blog post, we'll provide an overview of the Dhs 1169 form and discuss some of the key things you need to know about it. We'll also provide some tips on how to complete it accurately.

You will discover information about the type of form you would like to prepare in the table. It will tell you how long it takes to fill out dhs 1169 form, exactly what parts you will have to fill in, and so forth.

QuestionAnswer
Form NameDhs 1169 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedquest application, ulril, medquest oahu, med quest application

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STATE OF HAWAII

Med-QUEST Division

 

Department of Human Services

 

 

MAINTENANCE OF LIEN STATUS

PART I (To be completed by the Applicant/Beneficiary or Authorized Representative)

The State is required to place a lien on the home property of certain individuals who receive medical assistance who is an inpatient in a nursing facility or other medical institution. An inpatient in a nursing facility can include a person receiving HCBS or residing in a CCFFH or E-ARCH. The information you give us will be used to determine if the State should place a lien on your home property or maintain the present lien on your home property. The lien will be for medical assistance payments made on your behalf. The lien will not affect your ownership in the property, nor will it require you sell the property. The lien may be dissolved if you are discharged from the medical institution and return to live in the home.

 

Female

Male

Married

Divorced

Widow

Single

 

 

 

 

 

 

 

PRINT:

Last Name

First Name

M.I.

Date of Birth

Social Security Number

 

 

 

 

 

 

 

Name of Medical Institution

 

 

 

Date of Admission

 

 

 

 

 

 

 

Check the appropriate box:

1a. Do you still own an interest in a house, condominium, apartment or other property that you

 

 

lived in before you were admitted to the nursing facility or medical institution?

YES

NO

 

 

 

1b. Do you still own a life interest or life estate, lease or leasehold interest in a house

 

 

condominium, apartment or other property?

 

 

YES

NO

 

 

 

1c. Do you still have a trust that owns a house, condominium, apartment or other property?

 

 

If “YES”, please provide a copy of the trust.

 

 

YES

NO

1d. Do you still have a Transfer on Death Deed (TODD)? If “YES”, please provide a copy of the

YES

NO

death deed (TODD).

 

 

 

 

 

 

2. If you no longer own an interest in your home, did you sell or transfer your interest in the

 

 

home?

 

 

 

 

 

YES

NO

2a. If SOLD:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Buyers Name

 

Relationship to You

Date of Sale

Purchase Price

 

2b. If TRANSFERRED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Buyers Name

 

Relationship to You

Date of Sale

Purchase Price

 

3. Has anyone ceased living in your home in the past twelve (12) months? (If more space is

YES

NO

needed, please list this question number with their information on the back of this page.)

 

 

 

 

 

 

 

 

 

Name

 

Relationship to You

 

Date Moved OUT

4. Has anyone moved into your home in the past twelve (12) months? (If more space is needed,

YES

NO

please list this question number with their information on the back of this page.)

 

 

 

 

 

 

 

 

 

Name

 

Relationship to You

 

Date Moved IN

I HAVE READ OR HAD THIS DOCUMENT READ TO ME AND I UNDERSTAND ITS CONTENTS AND CERTIFY THAT I HAVE ANSWERED THE QUESTIONS TRUTHFULLY AND TO THE BEST OF MY KNOWLEDGE.

PRINT: Applicant/Beneficiary’s Name

Signature or Mark

Telephone #

 

Date

 

 

 

 

 

PRINT: Authorized Representative or Witness

Signature

Telephone#

 

Date

 

 

 

 

PRINT: Mailing Address of Authorized Representative or Witness

City

State

Zip Code

AUTHORIZED REPRESENTATIVE: DO YOU HAVE POWER OF ATTORNEY (POA)?

YES NO

 

 

IF “YES”, YOU MUST ATTACH A COPY OF POWER OF ATTORNEY OR GUARDIANSHIP DOCUMENT AND PROVIDE YOUR CURRENT MAILING ADDRESS. Note: Person witnessing an Applicant/Beneficiary’s mark “X” has determined to the best of the witness’ knowledge that the Applicant/Beneficiary is competent and understands his or her actions in signing this document. The use of an “X” is because the Applicant/Beneficiary cannot physically sign the document. (The witness must also sign this document and provide a mailing address.)

PART II (To be completed by DHS)

DOC:

Reason:

 

Case Number:

 

 

Date sent to MQD/FO

 

PRINT Worker’s Name:

 

Telephone

#:

Section/Unit:

DHS 1169A (Rev. 11/2020)

 

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