(check one) Single Married Separated Divorced Widowed
Phone If not yours, whose number is it
Date of Birth / /
Sex(optional) Male Female Doctor’s Name Phone
Name of your Home Health/Adult Day Care Agency Phone
Medicaid Number Medicare Number
Medicaid Application Pending
INCOME AND ASSET INFORMATION
WHAT IS COUNTED FOR YOUR GROSS MONTHLY INCOME?
Your total income before any deductions including any deductions for Medicare premiums. $
Count only your income and no one else’s. (If married, do not count your spouse’s income.)$
Count all income you get on a regular basis like your wages, pension, Social Security, Veterans benefits, and Supplemental Security Income. $
WHAT ARE YOUR COUNTABLE ASSETS?
DO NOT COUNT:
your house, furnishings, personal belongings (clothes, jewelry) or the motor vehicle that is your essential means of transportation. Also, do not count:
- Irrevocable up to $5,400.00 for each person OR Revocable up to $1,800.00.
- For single individuals, one plot. For married individuals, one plot for each spouse and certain other family members under certain conditions. A plot may include a casket, outer container and opening and closing of the grave.
Life Insurance Policies
- If the total face value of all policies does not exceed $1,500.00. (Otherwise count total cash surrender value of all policies.)
COUNT ASSETS OWNED BY YOU OR YOUR SPOUSE
All jointly held assets must be counted in full as yours unless you can show they are owned by someone else (not your spouse). This includes things like: real estate not used as your home, non-essential motor vehicles, campers, boats, bank/credit union accounts (savings, checking, CD, IRA, Vacation or Christmas Club), stocks, revocable trust funds, bonds, U.S. Savings Bonds, total cash surrender value of life insurance with a total face value that exceeds $1,500.00. MEDICAID WAIVER INCOME LIMIT - $2,094.00 per month or less STATE FUNDED INCOME LIMIT - No Limit
-- $24,328.00* (one receiving services) (one or both receiving services)
A higher amount may be allowed if you have a spousal assessment done (see Notice to Married Couples).
Participation in program is based on availability of funds. State Funded clients are required to pay 7% of the cost of their services.
If your income and assets are within these amounts you may qualify for services.
When we do your home/office cleaning, you get the perfect combination of professional quality and personal service For more information or to start enjoying the benefits. Contact: the office (203)368-9451 or (203) 858-1764