Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care Page 5
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1013. Look at the list below. Check the box for anything on the list that you, your spouse, or other person in your home may own. For anything
that you check, please tell us about it on the lines below.
When we start working on your application, you may be asked to send in proof of the assets you tell us about.
Bank Checking Account
Bank Savings Account
Certificate of Deposit
Trust Fund or Trust Account
Safe Deposit Box
Car, Truck, Van
Annuity (If Yes, provide a copy)
Cash on Hand
(Include a list of the contents)
Stocks, Bonds, or Mutual Funds
Motorcycle, Boat, Camper
Farm Machinery or Business Equipment
Life Insurance
401K, IRA or other Retirement Account
Pre Need Burial Contract
Cemetery Burial Space
Money Set Aside for Burial
DirectExpress Debit Card for SSA, SSI or other benefits
Other
:
(Please be specific)
Tell us about the asset
Current Value or
Owned By
Include the location, such as the name of bank or funeral home,
Balance
and any account numbers or other information used to identify the asset
14. Do you or your spouse own any property?
If you answer YES to any of the following questions, please tell us about the property on the next page.
Home (house, buildings and land where you live)
Yes
No
Other House or Building (not your home)
Yes
No
Land (not connected to the home)
Yes
No
Vacation Home or Time Share Property
Yes
No
What is the address/location of the property? List Home Property First
What is the address/location of the property?
Owner’s Name:
Owner’s Name:
Is this your Home Property or Primary Residence where you currently live or where
you want to return to live if you are living somewhere else?
Yes
No
DHHS Form 3401 (June 2016)
Page 5 of 9
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