Form Mc 262 - Redetermination For Medi-Cal Beneficiaries (Long-Term Care In Own Mfbu) Page 2

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10. Have you sold, transferred, or given away any property (including money) at any time in the past year?
Yes
No
Verification
If yes:
Date of Transfer,
Amount
Description
Sale, or Gift
Value
Received
$
$
$
$
$
$
11. Do you own any of the following items of property?
Check yes or no.
If yes, provide the other information requested.
Yes
No
Purchase Price
Current Value
Amount Owed
a. Stocks or bonds, certificates of deposit, money market,
or mutual fund account
$
$
$
$_________________
b. Jewelry valued over $100 (other than wedding or
engagement heirlooms)
$
$
$
Exempt
c. Burial reserve or trust
$
$
$
$_________________
d. Burial plot, vault, or crypt
$
$
$
$_________________
e. Business equipment, tools, inventory, or material
$
$
$
$_________________
f. Other
$
$
$
$_________________
Verification of CSV on file?
12. Do you own any annuities or life insurance policies or long-term care insurance policies for yourself or
$_________________
anyone else? ............................................................................................................................................
Yes
No
Copy of annuity on file?
If yes:
Yes
No
Current
State certified LTC policy?
Company
Name of Insured or Annuitant
Face Value
Cash Value
Yes
No
a.
$
$
Amount paid out $___________
b.
$
$
DHCS 6155 completed
c.
$
$
Yes
No
13. Do you own a motor vehicle (car, truck, etc.); or a boat, camper, or motor home; or mobile home or
trailer not taxed as real property?.............................................................................................................
Yes
No
Exempt
Yes
No
If yes:
Class Code
Description
(From Registration)
Year
Purchase Price
Amount Owed
$
$
$
$
$_________________
14. Do you or your spouse receive any income? ...........................................................................................
Yes
No
Use copy of award letter or
If income is received less often than monthly,
If yes, list the source and amount of income received each month.
check or other verification
indicate how often received.
Attach verification of this income.
When Paid/How Often
Applicant
Spouse
Social Security (green check)
$
$
$_________________
SSI/SSP
$
$
$_________________
Railroad retirement
$
$
$_________________
Veterans benefits (including Aid and Attendance payments)
$
$
$_________________
Retirement or pension
$
$
$_________________
Annuities
$
$
$_________________
Interest income or dividends
$
$
$_________________
Contributions (including those from relatives)
$
$
$_________________
Earnings (gross)
$
$
$_________________
Other (include lump sum payments, inheritance, etc.)
$
$
$_________________
15. a.
Have you or any family member ever been in U.S. military service?
..................................................
Yes
No
CA5 (if not already completed)
b.
Are you or any family member the spouse, parent, or child of a person who has been in U.S.
military service? ..................................................................................................................................
Yes
No
16. Have you applied for or do you think you are eligible for any payments you are not now receiving? ......
Yes
No
If yes:
Kind of Payment
Date Applied For
Date Expected
MC 262 (06/07)
Page 2 of 4

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