Arkansas Department Of Human Services Long Term Care Application For Assistance Page 6
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816. I and my spouse have income from the following: (Check (√) Yes or No. If yes enter the amount and how often the income is
received).
MYSELF
MY SPOUSE
HOW
SOURCE OF INCOME
YES
NO
AMOUNT
HOW OFTEN
YES
NO
AMOUNT
OFTEN
Retirement Benefits
Social Security Benefits
SSI
Veteran’s Benefits
Railroad Retirement
Civil Service Benefits
Interest/Dividends
Insurance
Money From Trusts
Mineral Rights/Oil Leases
Rental
Cash Contributions
Unemployment Benefits
Worker’s Compensation
Employment/Work
Farming/Self Employment
Deposits by Others for Me
Other
17. I or my spouse have received SSI in the past:
Yes
No
If Yes, when
18. I or my spouse expect a change in income:
Yes
No
If Yes, explain.
19. I or my spouse own a home.
Yes
No
If yes, my home is occupied by my spouse and/or dependent relatives.
Yes
No
Address of Home
Equity Value
I or my spouse formerly owned homes in:
City, County and State
City, County and State
20. I or my spouse own real property, (land or buildings), other than my home.
Yes
No
If yes, complete the following:
Address of Property
Equity Value
Address of Property
Equity Value
I or my spouse formerly owned real property other than my home in:
City,
County and State
21. I or my spouse have sold/deeded/given away a home or other real property:
To Whom
22. I or my spouse retain life estate, dower, curtesy, inheritance or other interest in a home or other property
Location of Property (City, County, State)
Type of Interest
Value
DCO-777 ((R.11/07)
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