Medical Assistance Application Form Page 2
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7- Page 2
MAD 381 Revised
G UA R DI A N I NF OR M A T I ON
3.
Name of Guardian – If you have a legal guardian or power of attorney
Court of Jurisdiction
Date Appointed Guardian
FOR COUNTY
/
/
OFFICE USE ONLY
Guardian’s mailing address – Street No./PO Box/R.Rt.
City
State
Zip Code
Telephone Number
Does applicant have
POA? (Copy for file)
PA R E NT I NF OR M A T I ON
4.
(If applicant is under age 18)
Name – Last
First
Middle Initial
Sex
F
M
Social Security Number
Medicare Claim Number
Railroad Retirement Number
Indian Census Number
-
-
-
-
-
Applicant/Representative
notified to pay MCC of
Name – Last
First
Middle Initial
Sex
$_________________
F
monthly to the nursing
M
home while application is
Social Security Number
Medicare Claim Number
Railroad Retirement Number
Indian Census Number
pending.
-
-
-
-
-
Resource/Transfer of
I NC OM E
5.
property policy explained
Have you or your spouse served in the military or worked for a railroad or for any federal, state, county or city government or for a private employer who had a
YES
NO
pension plan, or belonged to a trade union with a pension plan?
_____________________
Signature
If YES, complete the following:
DATES SERVED or EMPLOYED
_____________________
NAME of EMPLOYER (Agency, Service or Other)
From
To
Date
$ Gross Amount per Month
$ Gross Amount per Month
KIND of INCOME
KIND of INCOME
Applicant
Spouse/Parent
Applicant
Spouse/Parent
SCANS
SALE of PROPERTY
SOCIAL SECURITY
SSI
CIVIL SERVICE ANNUITY
HS02________________
RAILROAD RETIREMENT
EMPLOYMENT
_____________________
VETERANS BENEFITS
WORKERS COMPENSATION
UNEMPLOYMENT COMPENSATION
_____________________
CONTRIBUTIONS FROM RELATIVES/OTHERS
RENTAL from REAL PROPERTY
ROYALTIES
_____________________
INDIVIDUAL INDIAN MONIES
INTEREST/DIVIDENDS
ANNUITIES
RETIREMENT BENEFITS
_____________________
OTHER (Explain)
OTHER (Explain)
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