Question	Answer
Form Name	Tenncare Renewal Packet 2017
Form Length	9 pages
Fillable?	Yes
Fillable fields	338
Avg. time to fill out	34 min 57 sec
Other names	tenncare renewal pack, tenncare questionnaire to keep coverage, tc0131 form, tenncare renewal application


	Are you living in a shelter? Yes		No
English	Spanish	Other Language ______________
English	Spanish	Other Language ______________

If you do, do you need us to help you with these papers? Yes	No
TC0131 Rev: 30Oct18	RDA 2047

Who lives in your home now?	Does this	Date of	Social Security number:	How is this	Sex	Want to tell
List yourself first.	person want	Birth	ONLY if	person related		us your Race?
Full Name –	to qualify for	(Month/	this person wants	to you?	M /F	***
Full Name –	coverage	Day/Year)	coverage			(W, B, Y,
First, Middle Initial, Last	listed on the					A, H, I or O)
	previous
	page?
	Yes
	No
	Yes
	No
	Yes
	No
	Yes
	No

W = White	B = Black or African-American	Y = Hispanic
I = American Indian or Alaskan Native		O = Other

Are you getting care in a nursing home? Yes	No
If yes, what’s the name of the nursing home? _______________________________________________________

Are you temporarily living out-of-state? Yes	No
If yes, tell us where you’re living and why. _____________________________________________________

Is anyone a Veteran or in Active Military status? Yes	No
If yes, tell us who. Be sure to tell us their name and social security number.
___________________________________________	_________________________________________
___________________________________________	_________________________________________
TC0131 Rev: 30Oct18	RDA 2047


Do the other people listed in number 2 also have this insurance? Yes		No
If yes, tell us the names of the other people who are covered by this same health insurance plan:
___________________________________________	_______________________________________
___________________________________________	________________________________________

Does anyone in your home work? Yes	No	If yes, you can send copies of pay stubs or proof of
earnings for the last 2 months for each job. What if you don’t have all your pay stubs for the last 2 months?
Give TennCare copies of all that you have.

Is anyone self-employed? Yes No	If yes, tell us the kind of work they do.____________________

Name of person	# of	How much		How	Name of Employer				Phone number of
(Who earns this	hours	do they get		often do					Employer
money?)	worked	before taxes		they get	(Are you self-employed? Tell us the
	each	each pay		paid? ***	name of your business if it has one.)
	week	period?

		$

		$

		$

		$

			*** Daily, Weekly, Every 2 weeks, Twice a month, Monthly
Is there an adult in your home with no income? Yes						No	If yes, who? __________________
When did their income stop? ____________				How do they pay the cost of daily living?				For example, living with a

LTSS and MSP APPLICATION.3			Page 5 of 9
Does anyone get any of the kinds of income listed below? Yes No
• Money from friends or relatives		•	Workers’ Compensation
•	Retirement Payments	•	Interest/Dividends/Royalties
•	Disability Payments	•	Rental Income
•	Child Support Payments	•	Alimony
• Unemployment Payments from another state		•	Other

Name of person	What	How much	How often?	Who pays them?	What is their
(Who gets this money?)	kind?	do they get?		Who pays them?	Phone Number?
(Who gets this money?)	kind?	do they get?			Phone Number?

		$

		$

		$

		$

Who gets this care?	Who pays for this	How much	How often do	Name and Phone Number of Caregiver
	care?	does it	you pay?
		cost?
		$

		$

Yes	No	If yes, tell us who. _____________________________________________________________
You don’t have to send proof of this income. We’ll get it for you.

Do you own:		What’s it	How much do you	The kind of proof
		worth now?	owe on it?	we need:

Property Tell us these things about the				Something that shows what
property in the space below:				it’s worth like a property tax
				statement
				and something that shows
Street Address:		$	$	how much you owe like a
City:				how much you owe like a
City:				mortgage statement
State:	ZIP:			mortgage statement
State:	ZIP:

Street Address:		$	$
City:
State:	ZIP:


Do you own:		What’s it	How much do you	The kind of proof
		worth now?	owe on it?	we need:

Checking accounts		$		Statement from bank or
Bank Name: _____________________				credit union that shows the
				balance
Savings or credit union accounts		$		balance
Savings or credit union accounts		$
Bank Name: _____________________
Christmas Club accounts		$
Bank Name: _____________________
TC0131 Rev: 30Oct18				RDA 2047

LTSS and MSP APPLICATION.3							Page 6 of 9

Cars and trucks
Tell us the make, model and year below.
Make_________________________			$		$
Model	Year
Make_________________________			$		$
Model	Year

Make_________________________			$		$
Model	Year
							Payment book or signed
Motorcycles and boats							Payment book or signed
Make_________________________			$		$		statement that says how
Make_________________________			$		$		much you owe
Model	Year						much you owe
Model	Year

Make_________________________			$		$
Model	Year

RVs and campers
Make_________________________			$		$
Model	Year

Trust fund or Estate			$				Copy of legal papers
Trust fund or Estate
Stocks			Current				Bank or investment
Name:________________________			value:				company papers that show:
Number Owned: _______________			$				∙ the kind of stock or
Number Owned: _______________							∙ the kind of stock or
Bonds			Current				bonds,
Name:________________________			value:				∙ how many you own of
Name:________________________			$				∙ how many you own of
Number Owned: ________________			$				each kind, and
							each kind, and
							∙ how much they’re worth
IRAs and Keogh Plans			Account				Statement that shows the
			value:				balance. Are you drawing off
			$				this amount? Yes No
							If yes, how much? $

Savings Certificates or CDs			$				Statement from bank that
Tax Shelter Accounts			$				shows the balance
Revocable burial contract			$		$		Copy of the burial contract
Irrevocable burial contract			$		$		Copy of the burial contract

Cemetery Lots			$		$		A deed and something from
How many? __________							the cemetery that shows how
Are the lots for you or members of your							much you could sell the lots
immediate family? Yes	No						for now
If no, for who?_________________
Other (Tell us what):			$		$

Does anyone in your household have a life insurance policy? Yes						No

Tell us who		What is its cash value?		Insurance Company Name and Phone Number
		$

		$

listed in question 6? Yes No		If yes, fill in the boxes below.

What did you sell or	What was it		How much did	If you sold	The kind of proof
give away?	worth?		you owe on it?	it, how	we need:
				much did
				you get?
	$		$	$	Something that shows:
					∙ how much it was worth, and
	$		$	$	∙ how much it was worth, and
					∙ how much you owed on it,
	$		$	$	∙ how much you owed on it,
					and
	$		$	$	and
					∙ how much you sold it for

Tell us who	How much did	Where did it come from?	The kind of proof
	this person get?		we need:
	$		Bank records or an award
			letter that shows how much
	$		letter that shows how much
	$		you got.

	$
	$

Sign Here X: ________________________________________	Date: ________________________
Person Applying / Head of Household

Witness Print your name: ____________________________________	Date: ________________________
TC0131 Rev: 30Oct18	RDA 2047

Rent or mortgage	Utilities
Property tax	Homeowner’s insurance

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