Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care Page 4
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9ASSET TYPE
Still Have It
No Longer Have It
New
For each type, answer:
For each type, answer:
When did you or they
Tell us if the person getting
What happened to it?
Answer each
get it?
Medicaid or their spouse has
question below.
How much is it worth?
this item.
When did you or they get
Name of bank or
rid of it?
company.
What is inside?
What is inside?
Safe-Deposit Box:
Never had it
No longer have it
Still have it
New: Got it in past year
How much is it
Land, Second Home (not home
worth?
property):
Never had it
No longer have it
Still have it
New: Got it in past year
How much is it
Car, Truck, Camper, Boat, ATV,
worth?
Motorcycle:
Never had it
No longer have it
Still have it
New: Got it in past year
How much is it
Other ______________________:
worth?
No longer have it
Still have it
New: Got it in past year
9. Give us more information about annuities belonging to the person getting Medicaid and
their spouse. No Annuities – Go to Question 10
If more than 2, use another sheet of paper.
Annuity #1
Date Purchased
Beneficiary
Remainder Beneficiary
Annuity #2
Date Purchased
Beneficiary
Remainder Beneficiary
10. Does the person who gets Medicaid own or co-own a home? Yes – Fill Out Below No
– Sign Form on the Next Page
List all owners.
How much is it worth?
How much is owed on it?
Give us information about it like the location, lot size or number of acres, and if there are buildings on it.
Does anyone live in the home? Yes – Fill Out Below No – Sign Form on the Next Page
What is their relationship to the person who gets Medicaid? Spouse Child Parent Brother/Sister
Someone else (give name)
Is this person paying rent to live there? Yes No
How much is paid every month? $
This is the end of the form. You must sign the form on the next page.
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Parent category: Medical