Income And Asset Worksheet
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4INCOME AND ASSET WORKSHEET
(Medicaid)
I. General Information
Institutionalized Person______________________________________________________
SS # _________________ Birth date____________ Citizenship ______________________
Nursing Home______________________________________________________________
Date entered Hospital________________________________________________________
Date entered Nursing Home___________________________________________________
Veteran: Yes________ No ________
Spouse/Other(specify)________________________________________________________
Address___________________________________________________________________
City____________________________________State__________Zip__________________
Phone___________________________________Birth date__________________________
SS#________________________________ Citizenship ____________________________
Veteran: Yes_________ No _________
PLEASE BRING A COPY OF ANY ESTATE DOCUMENTS FOR THE ABOVE
PERSON(S).
Yes No
Is there a Guardianship or Conservatorship for the institutionalized spouse? If your response
is "Yes," provide a copy of Guardianship and/or Conservatorship appointment papers from
the court
Yes
No
Is there a disabled adult child? If yes please provide information in the “Disability” section
below.
Yes
No
Has any child age 21 or over lived in the homestead for at least two years immediately
before the client’s admission to the nursing home and provided care that would otherwise
have required nursing home care as documented by a physician's (M.D. or D.O.) statement.
Yes
No
Are there any co-owners of the home? If yes please provide information in the “Deeds”
section below.
Yes
No
Is the home in a trust? If yes please provide information in the “Deeds” section below
II. Income
Answer every item YES or NO. For each YES, specify monthly amount and payee (who receives the
income). Bring documentation for all YES answers.
Amount
Payee
Yes
No $_____________
___________________ Social Security, Client
Yes
No $_____________
___________________ Social Security, Spouse
Yes
No $_____________
___________________ Supplemental Security Income
Yes
No $_____________
___________________ Retirement Benefits (pension, IRA, Keogh,
401K, other)
Yes
No $___ _________
___________________ Veteran’s Benefits
Rev Feb. 2008
Page 1 of 4
J. Schuster Certified Elder Law Atty
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