Form Des 202 PDF Details

Form Des 202 is a document that is submitted to the IRS by certain tax-exempt organizations. This form is used to provide information about the activities of the organization and its directors, officers, and other key employees. Form Des 202 must be filed annually with the IRS by all tax-exempt organizations except churches and small associations of members. In addition, section 6033(a)(2) of the Internal Revenue Code requires all 501(c)(3) organizations to file an annual return on Form 990 or 990-EZ.

To look at a few specific details pertaining to the file you intend to use, here is the facts you might like to look at before filling out the form des 202.

QuestionAnswer
Form NameForm Des 202
Form Length3 pages
Fillable?Yes
Fillable fields62
Avg. time to fill out13 min 13 sec
Other names320d, pursuant, E-mail, LLC

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MEDICAID/MEDICARE BUY-IN APPLICATION

Page 1

 

 

 

 

Demographic Information:

 

Please complete all information for you and your spouse. If no spouse, indicate “None”.

 

Your Name (Applicant):

First

 

MI

 

Last

Your Social Security Number:

 

Sex:

Name of Spouse:

 

 

Male

Female

 

First

 

 

 

 

MI

 

Last

 

 

 

Spouse’s Social Security Number (if applying):

 

 

 

 

 

 

 

Sex:

Male

Female

Do you and your spouse live together?

Yes

No

 

 

 

 

 

 

 

Your Medicare claim number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s Medicare # (if applying):

 

 

 

 

 

 

 

 

 

 

 

 

 

Living Address: ______________________________________________________________________________________________

Number

Street

Apt #

City

Zip Code

Mailing Address: ______________________________________________________________________________________________

NumberStreetApt #CityZip Code

Telephone Number:

Telephone #

Contact Person:

__________________________________________________________________________

 

(Other than Yourself)

First

Last

 

MI

 

 

______________________________________________________________________________________________

 

Number

Street

Apt #

City

Zip Code

___________________________________

Telephone #

Relationship of Contact Person to you:___________________________________________

Do you want eligibility determined for the

 

 

three months before the month of application?

Yes

No

Technical Information:

Please complete all information for you and your spouse.

Date of Birth:

________________

________________

 

 

 

You

Spouse

 

 

Are you a U.S. Citizen? You:

Spouse:

 

 

 

Yes

No

Yes

No

Date Stamp: (Official DCF use only)

If not a citizen, provide alien number and status: __________________________________ ; __________________________________

You

Spouse (if applying)

Do you intend to remain in the State of Florida? You:

Yes

Do you and/or spouse have any other insurance other than Medicare? If Yes, Complete the following information:

Spouse:

NoYes No

You:

 

Spouse:

 

Yes

No

Yes

No

______________________________________________________________________________________________________________

Name of Other Insurance CompanyOther Insurance Policy Number

______________________________________________________________________________________________________________

Address of Other Insurance Company

Who is Covered by This Insurance

CF-ES 2282, PDF 07/2006

 

BUY-IN APPLICATION

 

 

 

 

 

Page 2

Asset Information: Please list all assets owned by you and/or spouse (even if your spouse is not applying).

TYPE

NAME OF BANK/

ADDRESS

ACCOUNT NUMBER

VALUE OF

IN WHOSE NAME

 

FINANCIAL INSTITUTION

 

 

ASSET

IS IT HELD

CASH

 

 

 

 

 

 

 

 

 

 

 

SAVINGS ACCOUNT

 

 

 

 

 

 

 

 

 

 

 

CHECKING ACCOUNT

 

 

 

 

 

 

 

 

 

 

 

CAR

 

 

 

 

 

Make/Model/Year:

 

 

 

 

 

 

 

 

 

 

 

HOMESTEAD

 

 

 

 

 

 

 

 

 

 

 

OTHER PROPERTY

 

 

 

 

 

 

 

 

 

 

 

TRUST FUND

 

 

 

 

 

 

 

 

 

 

 

STOCKS/BONDS

 

 

 

 

 

 

 

 

 

 

 

TAX SHELTERED

 

 

 

 

 

ACCOUNTS

 

 

 

 

 

LIFE INSURANCE

 

 

 

 

 

 

 

 

 

 

 

KEOGH PLAN

 

 

 

 

 

 

 

 

 

 

 

Other: Please Specify

 

 

 

 

 

 

 

 

 

 

 

Income Information: Please complete all information for you and your spouse (even if spouse is not applying).

Are you or your spouse self-employed?

Applicant

Yes

No

Gross Amount

 

 

Earned Monthly

Spouse

Yes

No

Gross Amount

 

 

Earned Monthly

Do you or your spouse work for someone else?

Applicant

Yes

No

Gross Amount

 

 

Earned Monthly

Spouse

Yes

No

Gross Amount

 

 

Earned Monthly

Do you or your spouse receive income from any of the following?

 

 

Gross Amount Received Each Month

 

 

(Before Any Deductions)

Type

Benefit No.

Applicant

Spouse

Veterans Benefits

 

 

 

Pension

 

 

 

Interest/Dividends

 

 

 

Civil Service Annuity

 

 

 

Income from another person

 

 

 

Black Lung

 

 

 

Social Security

 

 

 

Other (e.g. SSI, Annuities): (specify)

 

 

 

 

 

 

 

CF-ES 2282, PDF 07/2006

BUY-IN APPLICATION

Page 3

YOUR RIGHTS AND RESPONSIBILITIES: Read this sheet before you sign your name.

YOU HAVE THE RIGHT TO:

Apply for assistance and have a determination of your eligibility made without regard to race, color, sex, age, handicap, religion, national origin, marital status or political belief.

Have a representative help you fill out the eligibility forms.

Have action taken on your application promptly and be notified of such action.

Be informed of other available services of the Department of Children and Families.

Request a fair hearing when you disagree with a decision of the Department of Children and Families.

Have the information about you and/or your spouse that is collected by the department treated confidentially in accordance with federal and state laws.

YOU HAVE THE RESPONSIBILITY TO (things you must do):

Assist in determining your eligibility by giving complete and correct information and provide written proof of information, as requested, within the time limits given.

Declare the citizenship or alien status for you and your spouse by signing the Medicaid/Medicare Buy-In Application.

File for any payments or benefits from other sources if this application, or other information, indicates that you or your spouse may be eligible for such payments or benefits.

Assign your rights to third party benefits and cooperate in reporting any insurance or other health plan that covers medical costs for you (and/or your spouse, if applying) unless good cause can be shown not to do so.

Report changes in your situation (e.g., income, assets) within 10 days of the change.

Report your (and your spouse’s, if applying) Social Security numbers. Without accurate numbers, we will be unable to provide Medicaid/Medicare buy-in benefits if you are determined eligible for any benefits.

IMPORTANT INFORMATION ABOUT MEDICAID:

Any person (including the designated representative) who knowingly withholds information or knowingly misrepresents the truth may be punished under federal or state law or both. If you get medical assistance for which you do not qualify, you may have to repay the cash value of that assistance.

Certification of Citizenship/Alien Status: I certify, under the penalty of perjury, by signing my name on this application, that I and my spouse (if applicable) are U.S. citizens or nationals of the United States or qualified aliens.

Certification: In signing this application, I swear and affirm, under penalty of perjury, that the information I have given on this application is correct and complete to the best of my knowledge. I have read and understand the above rights and responsibilities and important information about Medicaid.

Applicant

Go Back To Page 1

 

 

 

 

 

Signature:

 

 

Date:

 

Spouse

 

 

 

 

 

Signature:

 

 

Date:

 

 

 

 

 

 

 

 

 

Designated

 

 

 

 

Representative Signature:

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HELPING PERSON: (Official use only)

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

Signature of Individual Who Assisted Applicant in Completing Buy-In Application Form

In accordance with Federal law and our policy, the Department of Children and Families is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, religion, political belief, or marital status.

CF-ES 2282, PDF 07/2006

How to Edit Form Des 202 Online for Free

Very few things are easier than creating files using the PDF editor. There isn't much you have to do to manage the DES-202 document - just follow these steps in the next order:

Step 1: Click on the button "Get Form Here".

Step 2: After you have entered the editing page DES-202, you'll be able to notice all of the actions available for the document within the upper menu.

In order to fill in the document, enter the information the program will request you to for each of the following segments:

writing pursuant part 1

Note the necessary data in the box MailingAddress, Apt, Apt, City, City, ZipCode, ZipCode, Number, Street, NumberTelephone, Street, TelephoneNumber, ContactPersonOtherthanYourselfFirst, Last, and Number.

Completing pursuant stage 2

The system will ask you to provide particular significant data to automatically fill in the part You, Yes, Spouse, Yes, Spouse, You, Yes, and Yes.

Finishing pursuant step 3

It is important to define the rights and responsibilities of both sides in field NAMEOFBANK, ADDRESS, VALUEOF, ASSET, INWHOSENAME, ISITHELD, FINANCIALINSTITUTION, ACCOUNTNUMBER, CASH, SAVINGSACCOUNT, CHECKINGACCOUNT, CAR, MakeModelYear, HOMESTEAD, and OTHERPROPERTY.

stage 4 to entering details in pursuant

Prepare the document by checking the next sections: KEOGHPLAN, OtherPleaseSpecify, Areyouoryourspouseselfemployed, Applicant, Yes, GrossAmountEarnedMonthly, Doyouoryourspouseworkforsomeoneelse, Applicant, Yes, GrossAmountEarnedMonthly, Type, VeteransBenefits, Pension, InterestDividends, and CivilServiceAnnuity.

Filling in pursuant stage 5

Step 3: When you hit the Done button, your finalized form can be easily exported to any kind of your gadgets or to electronic mail provided by you.

Step 4: Produce a duplicate of each form. It would save you some time and help you avoid complications down the road. Also, your data will not be distributed or viewed by us.

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