Spousal Financial Data Form Page 2
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4SPOUSAL FINANCIAL DATA FORM
17. Assets: Please state the estimated fair market value, as of the date of this application, of the combined interest of you and your spouse
in all of your assets, without deduction for secured liabilities or exemptions as follows:
st
Total Amount on 1
Day of Month
Current Asset Amounts
When Entered Nursing Facility or Hospital
If not in nursing home leave
this column blank
Month
Year
Month
Year
Residence
1)
$
$
(Tax District Appraised Market Value)
Other Real Estate
2)
$
$
(Tax District Appraised Market Value)
Real Estate Notes Held
3)
$
$
Remaining Balance(s)
Remaining Balance(s)
Automobile(s)
4)
(1) $
(1) $
(2) $
(2) $
& Value of Each)
(Year, Make, Model
(3) $
(3) $
Recreational Vehicles
5)
$
$
or Travel Trailers
& Value)
(Year, Make, Model
IRA, Keogh, 401K
6)
$
$
$_______________ $_______________
(Circle the Appropriate One)
Applicant
Spouse
Applicant
Spouse
Checking Account(s)
7)
$
$
(Total of All)
Savings Account(s)
8)
$
$
(Total of All)
(s)
9) Money Market
$
$
(Total of All)
Certificate of Deposits(s)
10)
$
$
(Total of All)
Mutual Fund
11)
$
$
(Total of All)
Stocks
12)
$
$
(Total of All)
Bonds
13)
$
$
(Total of All)
Cash Value/Life Insurance
14)
$
$
$
$
)
)
(Show Face Amount of Each Policy and Cash Value)
Applicant (Face Amount
Spouse (Face Amount)
Applicant (Face Amount
Spouse (Face Amount)
$
$
$
$
Applicant (Cash Value) Spouse (Cash Value)
Applicant (Cash Value)
Spouse (Cash Value)
Annuity Contracts
(15)
$
$
$
$
(Show Current Cash Value)
Spouse
Applicant
Applicant
Spouse
Total of Assets (1-15)
$
$
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