Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 7
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29ASSETS*
* If applying for Medical Assistance - you are only required to answer these questions if there is anyone in your household
who is applying for Aged (65+), Blind or Disabled Medicaid, Spenddown Medicaid, Nursing Home, Waiver, Medicare Cost
Sharing, and/or Refugee Medical.
24. Does anyone in your household have cash on hand? …………………......…
Yes
No
If yes, who? _____________________________________ Amount: $_______________
25. Does anyone in your household have financial accounts? ............................
Yes
No
D34314000240729
If yes, list all accounts owned by you or anyone applying with you. Some examples of
financial accounts are Checking, Savings, 401K*, IRA*, Annuities, Money Market,
Stocks/Bonds/Mutual Funds, etc.
* Not Required for Food Stamps
Type
Account Owner(s)
Bank Name
Account Balance
Date Opened
26. Does anyone in your household have any vehicles? ...........................................................................
Yes
No
If yes, complete all columns. Some examples of vehicles are cars, trucks, boats or water craft,
motorcycles, snowmobiles, motor homes, ATV’s, etc.
Licensed
Amount
Date of
Registered Owner(s)
Make
Model
Year
State
Vehicle Use
Yes/No
Owed
Purchase
27. Does anyone in your household have any of the following property assets? ......................................
Yes
No
If yes, complete all columns:
Type
Who Owns This?
Fair Market Value
Amount Owed
Date Acquired
Home you live in
Land
Rental Home
Vacation Home/Time Share
Equipment/Tools
Machinery
Trailers
Livestock
Mineral/Other Rights
Other:
28. Does anyone in your household have any of the following other assets? ...........................................
Yes
No
Mark all that apply:
Life Insurance
Trust
Burial plot
Burial Plan/Contract
If yes, who? ___________________________________________________________________
29. This question is not required for medical assistance:
Has anyone in your household sold, traded, or given away any assets in the last three months? ......
Yes
No
If yes, explain: _________________________________________________________________
_____________________________________________________________________________
Page 7
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