Example Income Calculation Worksheet Page 6
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8SeniorCare Application Instructions
Page 6
F-10076A (09/11)
CHECKLIST
Is the application complete?
Did you sign or have your representative, legal guardian or power of attorney, sign the application?
Did you enclose your enrollment fee? ($30 for one person; $60 if you and your spouse are applying)
Did you remember to write the name of each person applying on your check or money order for the
enrollment fee?
Did you read the Rights and Responsibilities section?
Send the application form to:
SeniorCare
P.O. Box 6710
Madison, WI 53716-0710
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