Form Sfn 958 - Health Care Application For The Elderly And Disabled Page 6
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10SFN 958 (4-2017)
Page 6 of 10
For all items checked yes, fill in the boxes below:
Type of Asset
Location/Description
Total Value
Amount Owed
Owners
Yes
No
Are any assets subject to a "Transfer at Death"?
If yes, describe the property and approximate value.
Tell Us About the Income/Money Your Household Receives
Self-Employment
If yes, complete the following:
Are any household members self-employed?
Yes
No
Name of Household Member(s):
Name and Type of Business:
Date Business Started:
Employment
Are any household members employed?
Yes
No
If Yes, list information about pay from employment such as wages, commissions, bonuses, and incentives for all household
members. If employment stopped last month or this month, also list income received this month here.
How
Day or
Hours
Dates
Often
This Month's
Next Month's
Worked
Date of
Paid
Paid
Amount
Pay Before
Pay Before
Per
Next
Hourly
Household Member
Employer
Use Codes
Taxes (Gross)
Taxes (Gross)
of Tips
Week
Check
Pay
Below
How Often Paid Codes:
M - Monthly
2X - Twice a Month
W - Weekly
EX - Every Two Weeks
Other, specify:
Day Paid Codes:
M - Monday
T - Tuesday
W - Wednesday
TH - Thursday
F - Friday
S - Saturday
SU - Sunday
Have any household members received commissions, bonuses or
Yes
No
If yes, complete the following:
incentives other than those included above within the last year?
Name of Household Member:
Date Received:
Amount Received:
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