Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care Page 7
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1021. Has the applicant or spouse sold or given as a gift, any cash, property, vehicle, boat or other resource to any person any time in the past
five (5) years?
............................................................................................................................................................................................
Yes
No
Item Sold or Given Away
Person to Whom it was Sold or Given
Date Given or Sold
Amount Received
22. Where has the applicant lived in the past five (5) years?
City
County
State
From
To
23. If ever married, give the following information about the applicant’s spouse(s).
(List the most recent first.)
Name:
Living
In a medical facility
Separated – When or How long?
Married living together
Divorced Date and State/County where filed:
Married living apart (Not Separated)
Current Address:
Phone Number:
Deceased Date of Death:
State and County where estate was probated:
Name:
Divorced
Date of Divorce:
State and County where divorce was filed:
Deceased Date of Death:
State and County where estate was probated:
Name:
Divorced
Date of Divorce:
State and County where divorce was filed:
Deceased Date of Death:
State and County where estate was probated:
DHHS Form 3401 (June 2016)
Page 7 of 9
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