Crisis Medicaid Planning Questionnaire - Married

B. MEDICAL DATA
Name of Ill Spouse
First Last
Diagnosis
Course of Treatment
Where ill Spouse Currently Resides
Street Address City
Name of Well Spouse
First Last
Health of Well Spouse
Where Well Spouse Currently Resides
Street Address City
If either spouse has already entered a nursing home, please indicate the name of the nursing home and the first date entered on a continuous basis

C. MONTHLY INCOME $
Do not include interest and dividend income on this form. If there is a pension, please list the gross pension amount, including any monies taken out for federal income taxes, health insurance, or any other reason
Husband’s Monthly Income
Social Security Benefit Retirement Benefit (Gross) VA Disability Benefit Annuity Income Rental Income Total Monthly Income
Wife’s Monthly Income
Social Security Benefit Retirement Benefit (Gross) VA Disability Benefit Annuity Income Rental Income Total Monthly Income
D. MONTHLY COST OF NURSING HOME
Monthly Cost in $
Monthly Nursing Home Cost Monthly Incidental Cost Monthly Prescription Cost Monthly Other Cost Total Monthly Costs
The nursing home is paid through

DD
MM
Year
As such, if applicable, please provide the Medicaid per diem rate:
If the nursing home facility is located in New Hampshire, Kansas, Ohio, or PennsylvaniaAFFC will require the nursing home facility’s Medicaid per diem rate to develop the appropriate Medicaid Compliant Annuity Plan.
E. ASSETS/LIABILITIES
(Please insert the value of each asset/liability in the appropriate space.)
List of Assets: (use + button to add more rows)
Asset Value Liability

Include these asset above if available: AUTOMOBILE, CHECKING ACCOUNT, SAVINGS ACCOUNT, MONEY MARKET ACCOUNT, CERTIFICATES OF DEPOSIT, RESIDENCE, MUTUAL FUNDS, STOCKS, BONDS, ANNUITIES, IRA, OTHER REAL ESTATE, NURSING HOME DEPOSIT and Others.

F. LIFE INSURANCE
(Please insert the value of each life insurance in the appropriate space.) (Include address and policy No. in Company Name)
List of Life Insurance: (use + button to add more rows)
COMPANY NAME TYPE DEATH BENEFIT VALUE FACE VALUE CASH VALUE INSURED INSURED BENEFICIARY

It is very important to know the cash value and the death benefit of your life insurance policy. To obtain the cash value of the policy, please call your insurance agent, or call the insurance company directly.
G. GIFTS
Please list gifts made in excess of $100.00 in any one month, to an individual or group of individuals, within the past 60 months:
List of Gifts
Recipient Date Amount

(use + button to add more rows)
Have you ever filed a Federal Gift Tax Return?
- Yes
- No
If so, please state details
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Crisis Medicaid Planning Questionnaire – Married

COMPANY NAME	TYPE	DEATH BENEFIT VALUE	FACE VALUE	CASH VALUE	INSURED	INSURED	BENEFICIARY

Asset	Value	Liability

Recipient	Date	Amount