Application For Medicare Savings Program (Qmb, Slmb, Qi) Page 4
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4Questions 7, 8, and 9 are about resources (assets). Please give information for the applicants and their spouse.
Include resources owned individually and those owned jointly with someone else.
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7. Does anyone own life insurance?
Yes
No
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8. Does anyone own a car or other vehicles?
Yes
No
9. Place a
beside each type of resource below that anyone owns.
Mobile
Savings account
Bonds
Credit Union
Certificates of Deposit
home
Checking account
Trust fund
Funeral plan / trust
Stocks
Camper
Real
Cash
Stocks
IRA / retirement fund
Keogh / 401 plan
Estate
Life estate in property
Mineral Rights
Livestock
Farm Equipment
Other
10. Give us information about the applicants’ Medicare coverage.
Part A Effective Date
Part B Effective Date
Part D
Name
Medicare Number
(month, day, year)
(month, day, year)
(Yes or No)
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11. Do any of the applicants have other health insurance, such as Medicare Supplement policy?
Yes
No
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12. Do any of the applicants pay child support for children living out of the household?
Yes
No
13. Please read the statement below and sign your application.
CERTIFICATION
I certify under penalty of perjury, that all of the information I have provided is complete and correct to the best of
my knowledge and belief, and that I have received the “Rights and Responsibilities under the Medicaid and
Medicare Savings Programs.”
Signature
Date (month, day, year)
Signature of witness if signed with “X”
If this form is being signed by an authorized representative for the applicant, an Authorized Representative form
must be included when filing this application. State Form 53460 can be downloaded from
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Parent category: Medical