Free Declaration of Income and Assets and State Residency (COP) - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29314 (07/2008)

STATE OF WISCONSIN COP-DIA Wis. Stats. 46.27

DECLARATION OF INCOME AND ASSETS AND STATE RESIDENCY
COMMUNITY OPTIONS PROGRAM (COP)
(Care Managers: Refer to line by line Instructions when completing Declaration) Name ­ Applicant/Participant County of Residence PART I--RESIDENCY (Complete Part I at application only) Have you resided in the State of Wisconsin for the past six months? (See instructions to determine if this applies) Yes--Continue No--STOP, individual is not eligible for COP 100% State funding but may be eligible for Medicaid Waivers PART II--DIVESTMENT Ask both questions [see instructions to determine if a referral to the Income Maintenance (IM) Agency is appropriate] 1. Within the last 36 months have you or your spouse disposed of, given away, or transferred property (such as land, stocks, bonds, cash, etc.) including transfers of property to children, relatives or other persons? Yes No

2. In the last 60 months have you or your spouse set up a trust or have you added funds to a trust? (Exception: Exempt funeral
trusts described on page 5 of the instructions to this Declaration). Yes No PART III--INCOME AND ASSET INFORMATION FOR SSI RECIPIENTS ONLY: Fill in amount on Income line 4 below. For SSI recipients who live at home, go directly to Part V of this Declaration for signature and date. Enter zero on line 9 of COP Worksheet 1. Applicant is eligible without cost-sharing. It is not necessary to complete Asset information or information in Part IV. For SSI recipients who live in substitute care, complete this form and then complete applicable COP cost-share worksheet to determine cost-share. A. Monthly Earned Income B. Combined Assets of Client and Spouse Do not count the home, furnishings, one car, or burial trusts under $3000. If the spouse is not applying or is not eligible for Client Spouse COP, do not count his/her IRA. 1. Before-tax wages or salary 2. Before-tax income from selfemployment 1. Cash on hand 2. Savings Monthly Unearned Income 3. Checking 4. IRA (Do not count ineligible spouse's IRA) 3. Social Security, SSDI or Railroad Ret. 4. SSI 5. Certificates of Deposit 5. SSI-E 6. Money Market 6. Veteran's Pension 7. Life Insurance cash value if face 7. Pension / Annuities value exceeds $1500 8. Other, specify (i.e., count the value of 8. Interest / Dividend Income if $20xmo. * 9. Other (i.e., estates / trusts, net burial trusts that is over $3000, other rental income, farm income, business types of trusts, stocks, bonds, money income, worker's compensation, owed to you, etc.) unemployment compensation, alimony, child support, etc.) * Consult with IMW for exceptions. 9. Value of divested amount, if applicable A10 Total Monthly Earned & Unearned Income (Add Lines 1 ­ 9)

B10 Total Assets (Add Lines 1 ­ 9)

PART IV--MONTHLY EXPENSES 1. Impairment Related Work Expenses (IRWEs) (Do not include IRWEs again under # 3 or # 4 below) Client's impairment related expenses: TOTAL........................................................................................ Client's Spouse's

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F-29314 2. Monthly Court-Ordered Expenses Paid by the Applicant(s) Child support or family support: Maintenance or alimony: Court ordered guardian and guardian ad litem fees: Court ordered attorney fees: Other court ordered expenses (specify type) ___________________ TOTAL Monthly Out-of-Pocket Medical/Remedial Expenses Applicant's medical/remedial expenses Cost If applicable, list spouse's med/remedial

COP-DIA

Client's Client's Client's Client's Client's

Spouse's Spouse's Spouse's Spouse's Spouse's

3.

Cost

TOTAL 4. Monthly Expenses--County Determined (In COP Plan)

TOTAL

Are there other, non-medically related household expenses that impact your household and which are approved under the county's COP Plan? YES NO Applicant's other expenses Cost If applicable, list spouse's other expenses Cost

TOTAL PART V--SIGNATURE AND DATE

TOTAL

I have provided true and accurate information. I understand that the agency may request more detailed and documented information later. I have received information regarding the Estate Recovery Program. SIGNATURE ­ Applicant/Participant PRINT Name ­ Applicant/Participant Date Signed

If signed by a legal representative, specify legal authority (Guardian, Conservator, DPOA for finances, etc.)

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