Medical Assistance Application Form Page 3
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7MAD 381 Revised
– Page 3
$ Net Amount per Month
FOR COUNTY
KIND of INCOME
OFFICE USE
ONLY
SMALL BUSINESS
OTHER SELF-EMPLOYMENT
R E SOUR C E S
6.
Do you or your spouse/parent own any of the following money or property? Enter the value.
Value
Value
DESCRIPTION
DESCRIPTION
Applicant
Spouse/Parent
Applicant
Spouse/Parent
BUILDINGS – Other than home
STOCKS/BONDS/CDs
CASH/CHECKING/SAVINGS, or
LIVESTOCK (include Type & Number)
MONEY MARKET ACCOUNTS
TOOLS, EQUPMENT or OTHER valuable
LAND-
(include lots, acres, grazing permits
item (s) (describe)
and mining claims-type, number and location,
REAL ESTATE CONTRACTS
mineral deeds)
IRAs, KEOGH PLAN
ANNUITIES
LIFE ESTATE
OTHER
Do you or your spouse/parent own cars, trucks or other vehicles? YES
NO
If YES, complete the following:
MAKE and MODEL (Other description)
YEAR
OWNERSHIP of a HOME
ADDRESS
EQUITY VALUE
MARKET VALUE
Equity Value
YES
NO
Do you or your spouse own a home?
$__________
Are you or your spouse buying a home? YES
NO
Home Excluded
Are you, your spouse, minor child, or disabled child currently living in this home?
If no, do you intend to return?
YES
YES
NO
YES
NO
NO
BIRTHDATE
CHECK IF:
NAME (s) of OTHER PERSON (s) in the home
RELATIONSHIP to YOU
Blind
Disabled
Mo.
Day
Year
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Parent category: Business