Jim Schuster - Certified Elder Law Attorney

INCOME 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

Yes ,No $_____________ ___________________ Disability Benefits
Yes ,No $_____________ ___________________ Annuities
Yes ,No $_____________ ___________________ Rental Income or Land Contracts held
Yes ,No $_____________ ___________________ Worker’s Compensation
Yes ,No $_____________ ___________________ Child Support
Yes ,No $_____________ ___________________ Unemployment Compensation
Yes ,No $_____________ ___________________ Military Allotments
Yes ,No $_____________ __________________ Gaming Distributions (Casino Profit
Sharing)
Yes ,No $_____________ ___________________ Income from proceeds of a lawsuit
Yes ,No $_____________ ___________________ Other Income (Please specify)
III. Assets
Answer each item YES or NO. For each YES, list all assets owned by you and your spouse individually
or jointly AND all assets owned jointly by you or your spouse and any other person. For each, provide
the following:
1. Documentation which shows the current value of the asset.
2. "Snap Shot" date value (provide ONLY if a married Medicaid applicant) -- documentation showing
the asset value on the date the patient entered a long term care facility where s/he received
continuous care 30 days or longer (known as the “snap shot date” in Medicaid jargon). The “snap
shot" date is often the first date the patient entered a hospital, was there for three (3) days, and from
there transferred to a nursing home (the total number of days under long term care totaling 30 or
more). The “snap shot" date is used to determine the couple’s total “countable assets” (as defined
by Medicaid rules) during the “initial assessment” process.
3. For Medicaid applicants ONLY, documentation which shows the asset value three (3) months prior
to the date of your appointment with our office.
* If you provide computer printout statements please have the representative sign and stamp the
printout with the bank stamp.
Current "Snap Shot" Owner Name(s)
Value Date Value (specify “J” if jointly owned)
[
Yes,No $_________ $________ _________________ Cash on Hand or in Safety
Deposit Box
Yes,No $_________ $________ _________________ Checking Account
$_________ $________ _________________ “
Yes,No $_________ $________ _________________ Savings Account
$_________ $________ _________________ “
$_________ $________ _________________ “
Yes,No $_________ $________ _________________ Certificate of Deposit
$_________ $________ _________________ “
$_________ $________ _________________ “
Yes,No $_________ $________ _________________ Patient Trust Fund
Yes,No $_________ $________ _________________ Savings Bonds
Yes,No $_________ $________ _________________ Money Market Funds

Yes9No $_________ $________ _________________ IRA, Keogh, 401K or deferred
compensation acct
Yes.No $_________ $________ _________________ Trust Funds
Yes,No $_________ $________ _________________ Stocks or Mutual Funds
Yes,No $_________ $________ _________________ Annuities
Yes,No $_________ $________ _________________ T-Bills
Yes,No $_________ $________ _________________ Mortgage, land contract or
other notes payable to you
Yes,No $_________ $________ _________________ Life Insurance policies
Yes,No $_________ $________ _________________ Home
Yes,No $_________ $________ _________________ Real estate other than home
Yes,No $_________ $________ _________________ Car/van/truck/boat/camper/
trailer/snowmobiles/other
Yes,No $_________ $________ _________________ Funeral contracts
Yes,No $_________ $________ _________________ Burial plots, casket, etc.
Yes,No $_________ $________ _________________ Other (please specify)
Yes,No $_________ $________ _________________ Other (please specify)
Yes,No $_________ $________ _________________ Other (please specify)
IV. Trusts
Yes ,No Do you have a trust for the institutionalized person, spouse or a child? If so please write
down the name and date of the trust and supply us a copy.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________
V. Deeds
Yes ,No Do you have any real property, including the homestead? Any unrecorded deeds? Please
identify the property, the grantors (signors) and the grantees (recipients) and supply us a copy of the deeds.
__________________________________________________________________________________
__________________________________________________________________
VI. Gifts
Yes ,No Have you and/or your spouse given a monetary gift within the last 3 years? If YES, please
explain and bring all records of the gifts:
__________________________________________________________________________________
__________________________________________________________________________________
VII. One Time Payments
Yes ,No Have you and/or your spouse received a one-time cash payment in the last 36 months (3
years) such as an insurance settlement, lawsuit award, worker’s compensation, lottery winnings, etc.,

or do you have a pending lawsuit that may bring property or money to you? If YES, please explain and
bring all records of the payment: ____________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________
VIII. Disabled Children
Yes ,No Does the institutionalized person have a child who is under the age 65 and receiving
disability from Social Security? If so please identify the child and provide a copy of the awards of RSDI
(Social Security) benefits
__________________________________________________________________________________
__________________________________________________________________________________
IX. Documents
We will need the following documents. Please bring them with you to your appointment.
Yes ,No Copy of your and your spouse’s social security card.
Yes ,No Copy of your and your spouse’s drivers license (even if expired).
Yes ,No Copy of your and your spouse’s Medicare card.
Yes ,No Copy of your and your spouse’s health insurance card.
Yes ,No Utility bills for the month of application.
Yes ,No Recent statement of Veteran’s benefits.
Yes ,No Recent statement of Homeowner’s insurance.
Yes ,No Recent mortgage statement.
Yes ,No Recent rent statement for your spouse.
Yes ,No Recent condominium fee statement.
Yes ,No Recent special assessment statement.
Yes ,No Recent tax bills for your and/or your spouse’s home and any other property you and/or
your spouse own.
Yes ,No Recent health insurance premium statement for you and your spouse.
Yes ,No 2008 social security benefit letter for you and your spouse.
Yes ,No 2008 pension letter for you and/or your spouse or pension check stub.
Yes ,No Copy of any Long Term Care Insurance policies.
Yes ,No Copy of birth certificate, passport, naturalization papers, citizenship papers, or legal
residency documents
*Please keep us current with monthly statements for banks, money market accounts, brokerage
accounts, etc.