Arkansas Department Of Human Services Long Term Care Application For Assistance Page 7
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823.
I or my spouse own personal property such as cars, trucks, tractors or other farm machinery, trailers, boats, etc.: (If more than
three, please list on a separate sheet)
Item (Make, Model, and Year)
Equity Value
Item (Make, Model, and Year)
Equity Value
Item (Make, Model, and Year)
Equity Value
24.
I or my spouse own livestock (cattle, poultry, catfish, minnows, crickets, worms, etc.)
Yes
No
If yes, complete the following:
Type of Livestock and Number Owned
Value
25.
I or my spouse have the following assets. (Check (√) Yes or No. If yes, enter the amount/value, location of the asset, and name
of joint owner, if any.)
TYPE
YES
NO
AMT/VALUE
LOCATION OF ASSET
NAME OF JOINT
OWNER
Cash
Checking Account
Savings Account
Other Savings (Certificates, etc.)
Promissory Notes
Stocks
Bonds
Patient Fund Account
Mortgage
Burial Plot/Crypt
Burial Funds/Insurance
Life Insurance
Trusts
Other
26. I or my spouse have additional income and/or property (real or personal) that I was unable to list under items 16 through 23.
Yes
No
If yes, record your answer(s) on a separate sheet.
27. I or my spouse have other resources (real or personal property) that are being held for me by another individual.
Yes
No
If yes, complete the following:
Type of Resource
Location of Resource
Amt/Value
Type of Resource
Location of Resource
Amt/Value
28. I or my spouse have hospital/medical insurance coverage. Yes
No
If yes, complete the following:
Name and Address of Insurance Company
Policy No.
29. I have unpaid medical expenses from the past three (3) months.
Yes
No
30. I, or someone in my household, would like to learn to read, or to read better. Yes
No
31. Do you have Long Term Care Insurance? Yes
No
DCO-777 (R.11/07)
Page 3 of 4
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