Spousal Financial Data Form Page 4

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SPOUSAL FINANCIAL DATA FORM
monthly
18. Income: Give the estimated average current
income of you and your spouse, consisting of:
Applicant
Spouse
1) Social Security
____
____
____
____
Gross $
Net $
Gross $
Net $
2) Pension (
______________)
____
____
____
____
Gross $
Net $
Gross $
Net $
Source
3) IRA
$
$
Check One:
Monthly
Yearly
________________________
________________________
4) Income Annuity
$_______________
$_______________
(Pays out principal & Interest)
5) Interest Income
$_______________
$_______________
(CDs, Savings Accounts, Fixed Annuities, Etc.)
6) Dividends
$_______________
$_______________
(Stocks, Bonds, Mutual Funds, Etc.)
7) Rental Income
$_______________
$_______________
(Rent Houses or Buildings)
Oil or Gas Income
$_______________
$_______________
8)
Check One:
Monthly
Quarterly
Yearly
9) Farm Income
Rental Income (Yearly)
$
$
a)
Share Crop (Yearly)
$
$
b)
Government Subsidy (Yearly) $
$
c)
Sale of Livestock (Yearly)
$
$
d)
Crops (Yearly)
$
$
e)
10) Hunting Lease Income (Yearly)
$_______________
$_______________
11) Other Income (Describe)
$_______________
$_______________
__________________________________
$___________________
$___________________
__________________________________
$___________________
$___________________
TOTAL INCOME:
_____________
_____________
$
$
______________________________________________________________________________________________
Cost of Care $
(Daily Room Rate X 31 Days)
Drug Cost $
(Monthly Average)
Total Cost of Care $
If the applicant is in the nursing facility, is he/she currently on Medicare?
Yes
No
If Yes, how many days remaining?________
Monthly Cost of Medicare Supplement for Applicant $________________________________________
Do you have a Long Term Care Policy?
Yes
No If Yes, what are the daily benefits?
Outstanding Debts
1. SPS Fee
2. Balance to Nursing Home
a. Current Month
b. Succeeding Month
3. Other
a.
d.
b.
e.
c.
_____
f.
_________
The information submitted herein was given by me and to the best of my knowledge is accurate. If it is not accurate or is incorrect then I
take full responsibility for the information submitted.
Authorized
Date
Initials

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