Form Sfn 958 - Health Care Application For The Elderly And Disabled Page 5
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10SFN 958 (4-2017)
Page 5 of 10
If you have recently applied for disability and the decision by the Social Security Administration is still pending please
provide proof of your pending status along with this application.
List household members who are a a veteran, a spouse, parent, or dependent of a veteran, or are an active-duty member in the US Milatary:
Have household members received medical assistance in another state?
Yes
No
If Yes, When?
Which City, County, and State:
If yes, when did/will they start receiving nursing care services?
Does anyone in your household
Yes
No
require nursing care services?
If receiving nursing care services in a facility, which facility?
Tell Us About Your Medical Bills
Medicaid can help pay medical bills, including prescription costs, for up to three months
Yes
No
prior to the month of your application. Would you like help paying any of these bills?
If yes, list which months and provide verification of income, assets and expenses for those months:
Medicaid can allow unpaid medical bills older than three months to reduce your out-of-pocket
Yes
No
costs. Do household members have unpaid medical bills older than three months?
If yes, explain:
Tell Us About Your Household Assets
Assets
Check yes by the assets owned, jointly owned, or being purchased by household members. Check no, if none.
Yes
No
Yes
No
Annuities
Inheritance
Yes
No
Yes
No
Assets Owned with Another Person
Life Estate/Life Lease
Yes
No
Yes
No
Burial Plots
Mineral Rights (Oil, Gas, Gravel, Coal, etc.)
Yes
No
Yes
No
Burial Space Items (Casket, Vault, Marker, etc.)
Money Market Account
Yes
No
Yes
No
Business Accounts
Notes or Contract for Deed
Yes
No
Yes
No
Business Inventory/Equipment
Prepaid Funeral Plans
Yes
No
Cash on Hand
Real Property (Land, Rental Property, Buildings, etc.)
Yes
No
Yes
No
Yes
No
Certificates of Deposit
Retirement Funds (IRA/KEOGH/401K)
Yes
No
Checking/Credit Union Accounts
Safe Deposit Box
Yes
No
Yes
No
Yes
No
Debit Card Account (Not Checking/Savings)
Savings Bonds
Yes
No
Yes
No
Farm Equipment, Livestock, Stored Grain
Savings/Credit Union Accounts
Yes
No
Yes
No
Home/Mobile Home (Not Owner Occupied)
Stocks/Bonds/Mutual Funds
Yes
No
Yes
No
Home/Mobile Home (Owner Occupied)
Trusts
Yes
No
Income Producing Tools/Equipment
Other, specify:
Household Assets continued on next page
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