Real And Personal Property - Supplement To Medi-Cal Mail-In Application Form - Department Of Health Care Services
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3Department of Health Care Services
State of California—Health and Human Services Agency
REAL AND PERSONAL PROPERTY—Supplement to Medi-Cal Mail-in Application
FOR COUNTY
USE ONLY
Applicant’s name: __________________________________________________________________
Social security number:____________________________________
First
Middle
Last
Case Name:______
Please fill in the following. You can use additional sheets of paper if more space is needed.
________________
SECTION 1: Financial Institution Accounts—Check the box(es) next to the types of accounts you have.
Case Number:
________________
Banks, Savings/Loans, Credit Union
Deferred Compensation
Certificate of Deposit (CD)
Trust Fund(s)
Worker Number:
Savings or Checking Accounts
Annuity
Money Market
Mutual Funds
________________
Retirement Account,
IRA,
KEOGH
Stocks
Bonds
Other
Date:
________________
Fill in the following:
Verification (List):
Owner: ________________________________________________________
Owner:______________________________________________________
Account number:__________________
Current value:_________________
Account number: ________________
Current value:________________
Name of financial institution: ________________________________________
Name of financial institution: _____________________________________
Address: _______________________________________________________
Address: ____________________________________________________
Cash or uncashed checks:
Name on the check: ______________________________________________
Amount: _____________________________________________________
SECTION 2: Real Property/Notes, Mortgages, Deeds of Trust, Sales Contracts
Home (whether you live in it or not), other houses, apartments, ranch, land, buildings, mobile homes, or life estates in or outside of the U.S. or the
State of California:
Address or legal description of property: __________________________
Expenses on property:
__________________________________________________________
Interest
$ _______________
Yearly
Monthly
Verification of Income
and Expenses (List):
Name of owner:______________________________________________
Taxes and assessments
$ _______________
Yearly
Monthly
Does anyone live there now?
Yes
No
Utilities
$ _______________
Yearly
Monthly
How long have they lived there?_________________________________
Insurance
$ _______________
Yearly
Monthly
Name of person living there: ____________________________________
Upkeep and repairs
$ _______________
Yearly
Monthly
Verification (List):
Relationship to you: __________________________________________
If you/family member own a life estate property, please fill in the following:
If you do not live there now, do you want to return to that property to live
Address: ____________________________________________________
some day?
Yes
No
Do you/family member have an income interest in a life estate?
(You must notify the county within 10 days of any change in plans for living
Yes
No
at the property.)
Is the life estate producing/giving income?
Yes
No
Is the property currently listed for sale?
Yes
No
Mortgages, promissory notes, deeds of trust, sales contracts:
Full value of property (from tax statement): $ _______________________
Appraisal Provided:
Held in whose name: __________________________________________
Amount owed: $ _____________________________________________
Yes
No
Rent collected each month from the property: $_____________________
Value/balance: _______________________________________________
SECTION 3: Business—(Check each item “Yes” or “No.”)
Business/Self-employment checking/savings account or cash:
Yes
No
Business or Self-
Business equipment, vehicles, tools, inventory, or materials (including livestock, or poultry not for personal use):
Yes
No
employment Verified:
Yes
No
Type of equipment: _________________________________________________ Name on property: ______________________________________________
Description of item: _________________________________________________ Estimated value: $ _________________ Amount owed:$ ______________
Business real property, buildings, leases, licenses:
Yes
No
Description: _______________________________________________________ Name on property: ______________________________________________
Estimated value: $ _________________________________________________ Amount owed: $ ________________________________________________
Page 1 of 3
MC 322 (05/07)
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