Free F-20586 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20586 (Rev. 10/2008)

STATE OF WISCONSIN s.s. 46.25(2m)

STATEMENT OF CHILD'S ASSETS AND INCOME
This questionnaire is used to determine your child's financial eligibility for Wisconsin Medicaid through the Katie Beckett Program. The questions apply only to income and assets that belong to the child and which may be managed by parent(s) on behalf of the child. Income and assets of parents are not considered for purposes of determining eligibility. Name - Child's - Last First MI

1.

Does your child have ASSETS? Maximum total allowable is $2000.

No Yes If Yes, check source below and write in amount. Amount Attach required documentation, as explained below, for each * asset your child has. certificates of deposit ____________________ checking account ____________________ savings account (including U.S. Savings Bonds) ____________________ life insurance (current cash value, not death benefit) ____________________ stocks, bonds, mutual funds ____________________ 529 education plan * ____________________ UTMA & UGMA accounts * ____________________ trust fund or legal settlement * (include funding source) ____________________ sole or joint ownership of property (land, vehicle, building) ____________________ other - __________________________________ ____________________ * Attach a clear description of account, ownership, and amount to original Katie Beckett Program application; and at annual recertification if established after initial application or if a change in terms of conditions of the account has occurred. 2. Does your child have personal monthly (or other) earned or unearned INCOME? No Yes If Yes, check source below and write in amount. child support payment (amount on tax return / 12 / # of children) dividend or interest payments Social Security payment from parent or own employment Supplemental Security Income (SSI) check trust or custodial account distributions wages other - _________________________________ 3. Amount ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

In the past 36 months, has your child or you as parent(s)/legal guardian of finances, sold, traded, transferred or given away property, stocks, bonds, cash, or any type of asset or income listed above that previously belonged to this child? No Yes--If Yes, please describe each type, its fair market value, date it was divested, and amount secured on that date.

I CERTIFY that the information on this Assets and Income form and given in connection with it is a true and complete statement of facts according to my best knowledge and belief. I also understand that I may be asked to provide proof of any information given on this form and that giving false information may subject me to prosecution for fraud. I understand that if the above information changes, I am required to notify the Katie Beckett Program of these changes. I further understand that the agency may contact other persons or organizations to obtain the necessary proof of eligibility. Check here if child is unable to sign Date Signed SIGNATURE - Child (if individual is 14 to 18 years of age) SIGNATURE - Parent or Guardian I have observed and verified each item I initialed above. SIGNATURE ­ Agency Support and Service Coordinator / Katie Beckett Consultant Date Signed Relationship to Child Date Signed