Form Hfs 1229a - Nursing Home/supportive Living Facility Redetermination Report Page 2
Download a blank fillable Form Hfs 1229a - Nursing Home/supportive Living Facility Redetermination Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Hfs 1229a - Nursing Home/supportive Living Facility Redetermination Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5Section B: Resources (Continued)
Check Your Answer
Value
i. Trust Funds
Yes
No
j. IRA or Keough Account
Yes
No
k. Oil, Coal, Gas or Mineral Rights
Yes
No
l. Promissory Notes
Yes
No
m. Inheritance
Yes
No
n. Business or Farm Income producing property
Yes
No
o. Other
Yes
No
No
2. Do you own or pay on a house or mobile home?
Yes
If YES:
a. Do you regard the property as your home and intend
to return to it?
Yes
No
b. Does your spouse, minor child, disabled child, adult
child who provided care and lived in the home for 2
years, or your brother or sister live in the property?
Yes
No
c. Is the property vacant?
Yes
No
d. Does the property produce income?
Yes
No
e. Is the property listed for sale?
Yes
No
3. Do you own or pay on any other land or buildings?
Yes
No
If YES:
a. Is the property listed for sale?
Yes
No
b. Does the property produce income?
Yes
No
4. Do you have life insurance?
Yes
No
Name of Company
Policy Number
Face Value $
Name of Company
Policy Number
Face Value $
5. Do you have health insurance?
Yes
No
Does it cover long term care?
Yes
No
Name of Company
Policy Number
Premium Amount $
How Often Paid
6. Do you have other insurance?
Yes
No
Does it cover long term care?
Yes
No
Name of Company
Policy Number
How Often Paid
Premium Amount $
Section C: Transfer of Resources
During the preceding year, have you or your spouse:
Yes
No
• Consulted with a financial planner or an attorney?
• Sold or given away any resources such as cash, house, land, insurance, stocks, certificates of deposit, etc.?
Yes
No
• Closed any savings, checking or other financial institution accounts?
Yes
No
• Changed the way any resource is held? This includes, but is not limited to, adding a name to a house or deed or creating
No
a trust.
Yes
Page 2 of 4
HFS 1229A (R-11-12)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal