Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) Page 3
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15AG-095 (11-14) – Page 3
CLIENT’S NAME
DAARS ID NO.
D. Net Monthly Income Information
CLIENT
SPOUSE/HOUSEHOLD
TOTAL
Earned income
Retirement/pension
Investment income
Social Security
Supplemental Security Income
(SSI)
Veterans compensation
Veterans pension
Veterans aid & attendance (A&A)
Other
TOTAL CLIENT INCOME
TOTAL SPOUSE/HOUSEHOLD INCOME COMBINED TOTAL INCOME
Total monthly income
At or below 100% FPL .......................
Yes
No
Declined to state income
E. Monthly Expenses
CLIENT
SPOUSE/HOUSEHOLD
TOTAL
Housing
Food
Utilities
Medical
Insurance
Private pay assistance
Transportation
Other
TOTAL CLIENT EXPENSES
TOTAL SPOUSE/HOUSEHOLD EXP
COMBINED TOTAL EXPENSES
Total monthly expenses
Subtract Total Expenses from Total Income above and enter the
Total net income after expenses
F.
Insurance Information
MEDICARE NUMBER
ENROLLMENT DATE (optional)
QMB
SLMB
Yes
No
Yes
No
MEDICARE PARTS
A
B
:
D
EFFECTIVE DATE:
EFFECTIVE DATE
EFFECTIVE DATE:
AHCCCS / ALTCS NUMBER
AHCCCS PLAN NAME
COUNTY CODES (OPTIONAL)
INSURANCE/BENEFITS
VETERANS MEDICAL BENEFITS
HAS MEDICARE ADVANTAGE PLAN
Yes
No
Yes
No
G. Legal Planning
DURABLE POWER OF ATTORNEY
Financial .........................
Yes
No
Living will ......................................
Yes
No
Health .............................
Yes
No
DNR (Orange form) ......................
Yes
No
Mental health ..................
Yes
No
Burial arrangements, mortuary .....
Yes
No
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