Healthcare Application For The Elderly And Disabled Page 7
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10SFN 958 (3-2016)
Page 7 of 10
Tell Us About Your Household Assets (continued)
Tell Us About Your Household Assets
List household members who have made arrangements for funeral expenses or gave money, property, or insurance to someone else to
pay for funeral expenses:
Explain:
Do you expect changes in assets next month?
If yes, explain:
Yes
No
Transfer of Assets
Have household members sold, given away or transferred anything of value within the past 5 years?
Yes
No
If yes, list the items:
Date
Life Insurance
Does any household member have life insurance?
If yes, fill in the boxes below:
Yes
No
Name of Insured
Name and Address
Cash Surrender
Policy Number
Face Value
Owners
Person
of Company
Value
Vehicles
List vehicles (car, truck, motor home, snowmobile, motorcycle, 3 wheeler/4 wheeler, boat or other watercraft, camper, trailer,
etc.) owned, jointly owned or being purchased for all household members, even if the vehicle is not running or not in your
possession. Include vehicles licensed through North Dakota, tribal motor vehicle or another state.
Make/Model
Year
Value
Amount Owed
Owners
Tell Us About the Income/Money Your Household Receives
Have household members sold, given away or transferred any income or stream of
Yes
No
income within the past 5 years? (Example: annuity payments, VA improved pension)
If yes, explain:
Continue on next page
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