Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care Page 4

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12. Tell us about the income of each family member in the home.

NO ONE IN THE HOME HAS ANY INCOME

Before we can make a decision on your application, you may have to give us proof of income for the past 4 weeks.

If checked, explain how you pay your bills

Income from Employment

Name of person working

Employer’s Name

Employer’s Address

Employer’s Phone Number (including area code)

Gross amount earned per pay period before taxes? $

How often paid?

Weekly

Every two weeks

Twice a month

Monthly

Weekly

Every two weeks

Twice a month

Monthly

When is it paid?

Is anyone self-employed? .................................................................................................................................................................................

Yes

If yes, please send copies of all the Personal and Business Federal income tax forms most recently filed with the IRS. Include all forms and schedules.

Please tell us who is self employed and the name of the business:

Do you or anyone in your home receive, or have applied for, any other income? ......................................................................................

Yes

If Yes, check all boxes that apply and complete the table below

Social Security benefits

Supplemental Security Income

Child Support

(RSDI)

(SSI)

Disability benefits

Pension/retirement benefits

Unemployment benefits

Rental Income

Veterans Administration (VA) benefits