Property Supplement Form PDF Details

The Property Supplement form, an essential document issued by the State of California—Health and Human Services Agency, Department of Health Care Services, serves as a comprehensive means for applicants to declare their possessions when applying for Medi-Cal benefits. It is meticulously structured to cover both real and personal property, ensuring that all applicants provide a detailed account of their financial conditions. The form is divided into sections that encompass financial institution accounts, real property, business ownership, vehicles, and other valuable possessions. It also addresses potential property transfers within the recent 30 months, asking applicants to disclose if they have closed, sold, or transferred any assets, which is crucial for determining eligibility for medical aid. Additionally, the form incorporates privacy statements to reassure applicants about the confidentiality and lawful use of their information, underscoring the authorities' commitment to privacy protections. Through this detailed approach, the form seeks to streamline the process of assessing property and financial information, thereby facilitating a fair evaluation of Medi-Cal applications.

QuestionAnswer
Form NameProperty Supplement Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmcquay mc322, supplement, mc 322 spanish, mc322 form

Form Preview Example

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

FOR COUNTY

USE ONLY

Case Name:______

________________

Case Number:

________________

Worker Number:

________________

Date:

________________

Verification (List):

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:____________________________________

Expenses on property:

 

Interest

$ _______________

Taxes and assessments

$ _______________

Utilities

$ _______________

Insurance

$ _______________

Upkeep and repairs

$ _______________

Yearly

Yearly

Yearly

Yearly

Yearly

Monthly

Monthly

Monthly

Monthly

Monthly

Verification of Income and Expenses (List):

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: $_____________________

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: _______________________________________________

Verification (List):

Appraisal Provided:

Yes

No

SECTION 3: Business—(Check each item “Yes” or “No.”)

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: $________________________________________________

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

FOR COUNTY

USE ONLY

List Verification/

Estimates of Value/

Encumbrance

List Verification/

Estimates of Value/

Encumbrance

Appraisal Provided:

Yes

No

LTC Insurance Benefit Summary Provided:

Yes

No

Transfer or Receiving NF Level of Care?

Yes

No

See MC 176 PI

 

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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1. Whenever filling out the supplement, be certain to incorporate all of the needed fields within the corresponding area. This will help speed up the process, making it possible for your details to be handled without delay and accurately.

what is mc322 property supplemental form writing process shown (part 1)

2. The subsequent stage would be to fill out these blank fields: Address or legal description of, Yes, Yes, If youfamily member own a life, Yes, Is the life estate producinggiving, Yes, Mortgages promissory notes deeds, Held in whose name, Valuebalance, SECTION BusinessCheck each item, Yes, Yes, Yes, and Appraisal Provided No.

SECTION  BusinessCheck each item, If youfamily member own a life, and Is the life estate producinggiving of what is mc322 property supplemental form

3. The next section is normally pretty uncomplicated, SECTION VehiclesRecreational, Class Registration, Make and Model, Amount Owed, Owner, Year, Yes, B List any boats campers do not, Make and Model, Year, Class Registration, Owner, Amount Owed, Listed for Sale Used for Business, and Yes - these empty fields must be filled out here.

what is mc322 property supplemental form completion process explained (portion 3)

It's easy to get it wrong while completing the Amount Owed, and so make sure to look again prior to when you finalize the form.

4. Completing cid Life insurance, Yes, Enter how many policies owned, If more than one use additional, cid Longterm care insurance, Yes, Name of insurance company Policy, cid Other accountsitems, Yes, Name on accountitem Value, SECTION Transfer Check Yes or No, No Item Date, Yes, Transferred, and Sold is vital in the fourth stage - don't forget to be patient and take a close look at each empty field!

Part # 4 in filling in what is mc322 property supplemental form

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