Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80783A (01/09)

STATE OF WISCONSIN

FAMILY FINANCIAL QUESTIONNAIRE
Modified for County Use

Completion of this form meets the provisions of DHS 1.02(6) and 1.03(8), Wisconsin Administrative Code. Failure to complete the form may result in the full cost of care being charged. Provision of social security numbers is voluntary; however, it is a unique identifier used to ensure proper identification of the individuals listed on this form. Personally identifiable information on this form will be used only for billing and collection purposes as specified in s. 51.30, Wisconsin Statutes.
CLIENT ­ Name

Social Security Number

Birth Date

Marital Status

Home Address ­ City, State and Zip Code CLIENT'S FAMILY ­ List only the family members who are dependant on family income. Relationship to Client Spouse of a married client Mother of a minor client Father of a minor client Stepparent of a minor client
DEPENDENTS

Home Telephone No.

(
Name Birth Date

)

Address and Telephone No. (if different than client's)

A child is considered a dependent if one of the following is true about the child: 1. The child is under age 18 2. The child is a full time student under age 25 and parents provide at least ½ of support. 3. The child meets some other IRS standard as a dependent. Child No. and Sex Name Birth Date Address (if different than client's) (circle) Female Female Female Female Female 1. Insurance Company - Name and Address

1. Male 2. Male 3. Male 4. Male 5. Male

MEDICAL INSURANCE

Insurance Type Client is Covered Under Hospital Insurance HMO Group Insurance Policy Number If client has group insurance, provide "Employer's Name and Address"

Insurance Type Client is Covered Under Hospital Insurance HMO Group Insurance Policy Number

2. Insurance Company - Name and Address

If client has group insurance, provide "Employer's Name and Address"

VETERANS ADMINISTRATION - Claim No.

Service Branch
MEDICAL ASSISTANCE NO.

Service No. Current Yes Date Certified No

RAILROAD RETIREMENT NO.

F-80783A Page 2

ASSETS
Item Home Other Real Estate Automobile Checking Accounts Savings Stocks & Bonds Market Value Insurance Cash Value Retirement Funds & Annuities Snowmobiles Etc. Bonds Etc. Livestock Machinery Other-Specify: Location or Description Value Amount Owed on the Asset Monthly Payment Lender or Mortgage Holder

DEBTS NOT LISTED WITH ASSETS
Creditor Amount Due Monthly Payment Creditor Amount Due Monthly Payment

F-80783A Page 3

INCOME
If you do not wish to complete this page, you must submit a copy of your most recent Wisconsin State Tax Return including all attached Federal Schedules. A. INCOME FROM EMPLOYMENT. List earnings of the persons named on page 1. If a child is a full-time student, omit the child's income from employment and self-employment. Other Deductions Income Per Pay Period Person Social Employer Name, Address *Pay Security No. Period Besides Social and Work Telephone No. Gross Net Security & Code Taxes? Specify Below. Client

Spouse of Client

Mother of Minor Client

Father of Minor Client

Stepparent

Child Not in School (Name) Child Not in School (Name) *Pay Period Codes: (A) Weekly B. (B) Bi-Weekly (C) Twice Per Month (D) Monthly

INCOME FROM SELF-EMPLOYMENT ­ FARM OR BUSINESS 1. Show Annual Amounts. 2. To do this section, refer to your most recent tax returns and records. Pay particular attention to 1040 Schedules C & F. Principle Paid on Wages Paid of Family Owner(s) Net Taxable Depreciation Depreciated Business or Members on This Income Claimed Property Form

C.

INCOME FROM RENT, PARTNERSHIPS AND S-TYPE CORPORATIONS NOT REPORTED IN SECTION B., ABOVE. 1. Show Annual Amounts 2. To do this section, refer to your most recent tax returns and records. Pay particular attention to 1040 Schedule E. Principal Paid on Wages Paid to Family Owner(s) Net Taxable Depreciation Depreciated Rental Members on this Income Claimed Property Form

F-80783A Page 4 D. OTHER INCOME RECEIVED MONTHLY BY FAMILY MEMBERS. Enter monthly income amounts received by family members. If income is irregular, show average monthly amounts over the past 12 months. Spouse Minor Income Type Client Mother Father Stepparent of Client Children Social Security Veteran's Pension Pensions Annuities Supplemental Security Income Interest Dividends Family Support Alimony Child Support Unemployment Compensation Worker's Compensation AFDC Other Other

FAMILY EXPENSES
Item Rent Home Mortgage (Should be the same as page 2) Real Estate Tax ­ Not paid with mortgage Heat: Gas / Oil Bills Electricity Water / Sewer Telephone Homeowner's or Renter's Insurance Food and items bought at grocery store Meals purchased away from home Clothing purchases and care costs Automobile: Gas and Oil Upkeep and Repairs Insurance Bus Fare Other transportation costs Life Insurance Health and Accident Insurance I understand that the statement made in this application must be and are to the best of my knowledge, true and correct. I also understand these statements may be verified. SIGNATURE Date Signed Total Monthly Payments Other Than Home Mortgage from Page 2 Other Expenses ­ Specify: Monthly Payment Item Union or Professional Dues Employment Expense ­ If not reimbursed Medical Health Expense Not Covered by Insurance Dental Expense Not Covered by Insurance Day Care Expenses School Expense Court Ordered Payments Payer Payment Type Amount Monthly Payment