Form Mc 210 Ps – Fill Out and Use This PDF

2.

3.

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).

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.

5.

6.

Business accounts and property.

If yes, please provide tax returns, invoices, receipts, licenses, profit and loss statements, etc.

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.

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.

7.

Yes, I intend to return home someday.

No, I do not intend to return home someday.

Please list the address of the property here: __________________________________________

No verification is required if you answered that you do intend to return home someday. If you answered that you do NOT intend to return someday, please submit a copy of the most recent tax assessment. If you choose to, you may provide an appraisal from a qualified real estate appraiser and that value will be used if it is lower.

Other real estate, condominiums, buildings, mobile homes, life estates, time shares, oil and mineral rights.

If yes, please provide copies of the mortgage papers, most recent tax assessment, registration, or ownership documents.

8.

9 .

Motorcycles, trailers, boats, or other motorized vehicles that are not used by you as a home.

Please provide a copy of the ownership documents or most recent registrations, purchase agreements, sales receipts, or estimates of value from a qualified source. On the submitted verification for each item, indicate if the item is used:

ｏon the job (such as a taxi);

ｏto travel long distances to work (such as a truck used by a contractor working out of town);

ｏto carry the main supply of fuel or water for your home;

ｏto transport a disabled or incapacitated family member living in the home or if it is business property.

Jewelry (not wedding rings, engagement rings, or heirlooms) worth more than $100.00.

If yes, please provide copies of sales receipts, appraisals, estimates of value or insurance documents.

10.

11.

1 through 10.

Any other real or personal property, assets, or resources valued at $500 or more.

If yes, send copies verifying the property and its worth.

Has anyone spent or used any of the items listed above in payment for, or as security for medical services?

If yes, please explain below and attach verifications.

If you owe money on any of the items listed above, or if any of the items listed above have liens against them, please provide copies of the lien, loan, or security documents.

12.

Did you, or any family member in the home, sell or give away any money or property in the past

ｏ 36 months (or 60 months if the transfer was made to or from a trust or agreement for holding money or property for the benefit of someone) if you are applying for Medi-Cal; or

ｏ12 months if you are currently receiving Medi-Cal?

If yes, please explain in the “Additional Information” section at the end of this form and attach verifications.

13.

Does any family member in the home have a checking account or savings account?

If yes, send copies of account statements showing current balances in the accounts.

14.

15.

Does anyone have a court-ordered settlement or judgment?

If yes, send copies of all court orders, documents, and agreements. If copies have already been provided to your worker, you do not need to provide them again.

Does anyone have life insurance or long-term care insurance?

If yes, send copies of your policies, contracts, and purchase agreements. If copies have already been provided to your worker, you do not need to provide them again. If your policy is a certified California Partnership for Long-term Care policy, send a copy of your most recent benefit statement.