Real And Personal Property - Supplement To Medi-Cal Mail-In Application Form - Department Of Health Care Services Page 2

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FOR COUNTY

SECTION 4: Vehicles/Recreational Vehicles

USE ONLY

A. List all cars, trucks, motorcycles, airplanes, snowmobiles, or off-road vehicles (even if not running) owned by you or your family. If none, write “none.

List Verification/

Listed for Sale?

Used for Business?

Estimates of Value/

Make and Model

Year

Class (Registration)

Owner

Amount Owed

Yes

Encumbrance

B. List any boats, campers (do not include trucks), motor homes, or trailers which are not used as a home and are not taxed as real property by the county.

List Verification/

Listed for Sale?

Used for Business?

Estimates of Value/

Encumbrance

Make and Model

Year

Class (Registration)

Owner

Amount Owed

Yes

If you do not agree with the value DMV gives your vehicle(s) listed above in A and B, you may get another estimate of the value from a qualified professional.

SECTION 5: Other—Do you/family member own:

Jewelry worth more than $100 (not wedding/engagement rings or heirloom):

Yes

Listed for sale?

Yes

Value: $_______________

Amount owed: $ _______________

Who owns: ____________________________

Household goods or any personal items valued at more than $500 per item (musical instruments, PC, etc.):

Yes

Appraisal Provided:

Value: $ _____________

Description: __________________________________________________________

Jointly owned

Separately owned

Yes

Mineral rights or mining claims (oil, coal, etc.):

Yes

Is either listed for sale?

Yes

Description: ______________________________________

Who owns: ____________________________

Current value: $ _____________

Amount owed: $ _____________ Location: ______________________________________________________________

Burial trusts or contracts, insurance, designated burial funds/money for cemetery plots, caskets, or other burial items:

Yes

Is it for use of immediate family?

Yes

Description: ______________________________________________________

Who owns: _______________________

Current value: $ _____________

Amount owed: $ _____________

Location: ______________________________________________________________

Purchase price: $ ____________

Purchased for whom: ________________________________________________ Account number: _______________________________________________

Life insurance:

Yes

Enter how many policies owned: ______________

If more than one, use additional sheet of paper.

Insurance company:____________________________________________

Person insured:__________________ Policy owned by: __________________

Face value: $ _______________

Policy number:____________________

Date policy issued: _______________ Current cash value: $_______________

Long-term care insurance:

Yes

Name of insurance company: _____________________________________________________________________

Policy number:____________________

LTC Insurance Benefit

Amount of benefits paid by the insurance company to date: $ ________________

Name on policy: ______________________________________________

Summary Provided:

Yes

Other accounts/items:

Yes

Name on account/item: ______________________________________________

Value: $ ____________________________________________________

SECTION 6: Transfer (Check “Yes” or “No.”)

Transfer or Receiving

NF Level of Care?

Has anyone closed, given away, transferred, sold, or traded any money, vehicles, or other property like those listed above in the last 30 months?

Yes

If yes, complete the following:

Item: _____________________________________________________________________

Date: ______________________

See MC 176 PI

Transferred

Sold

Traded

Closed

Given away

I declare under penalty of perjury under the laws of the State of California that the answers I have given are correct and true to the best of my knowledge.

Applicant’s signature

Date

Page 2 of 3

MC 322 (05/07)