Spousal Financial Data Form Page 3
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4SPOUSAL FINANCIAL DATA FORM
Assets (Continued): 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
Burial Plots
16)
$
$
$
17) Prepaid Burial Policies
$
$
$
$
Applicant
Spouse
Applicant
Spouse
18) Mineral Rights
$
$
Tax District Market Value if Producing
Tax District Market Value if Producing
19) Livestock
$
$
Number of Head and Value
Number of Head and Value
20) Farm Equipment
$
$
Value of All
Value of All
21)
Life Estate
Yes
No
Yes
No
(If yes, explain below)
22) Other current assets (list):
$____________________
$
$
$
__________________________
$
$
Total of Assets (1-15)
$
$
Total of Assets (16-22)
+ $
$
TOTAL ASSETS:
= $
$
23) Number of Married Children
____________________
Number of Unmarried Children
____________________
Notes:
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