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MEDICAID ASSET ASSESSMENT
F-10095 (07/15)
SECTION III – ASSET INFORMATION
RESIDENT
SPOUSE
NAME OF
OFFICE
OWNED
OWNED
PERSON WHO
USE
ASSETS
ASSETS
JOINTLY OWNS
ONLY
ASSETS
$
$
CASH VALUE
1. Life Insurance
$
$
FACE VALUE
2. Checking / Share-Draft Account
$
$
3. Other accounts in a bank, credit union, savings and loan or
$
$
other financial institutions
4. Cash that belongs to you (include the current amount in a
$
$
nursing home/institution patient account).
5. Money paid for anyone into a burial trust, or to another person
$
$
or place to pay for burial expenses.
6. Other property or money, not listed below:
$
$
Cash in a safety deposit box
Certificates of deposit
$
$
Farm equipment and livestock
$
$
Land/building (other than the place in which you live)
$
$
Money owed to you or your spouse
$
$
Notes / contracts of value
$
$
Retirement Accounts (IRA and Keough accounts)
$
$
Stocks or bonds (including U.S. Savings Bonds)
$
$
Commodities (Kruggerands, etc.)
$
$
Trust fund
$
$
7. Vehicles (List each vehicle and its value)
$
$
Vehicle 1:
Vehicle 2:
$
$
Vehicle 3:
$
$
8. Other Assets
$
$
SUB-TOTAL – Assets - Listed Above
$
$
TOTAL – Assets (Add sub-total amounts of resident and spouse)
$
Page 2

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