Free FORWARDHEALTH ANNUITY INFORMATION - Disclosure, F-10192 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10192 (01/09) § 49.47(4)(cr), Wis. Stats.

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ANNUITY INFORMATION - DISCLOSURE
INSTRUCTIONS Wisconsin State and Federal law requires you to complete this form for any annuity that you and/or your spouse own. Use a separate form for each annuity that you own. Return the signed, completed form(s) to your local county or tribal agency at the address listed on page 2. Failure to submit this completed form will result in a denial or termination of ForwardHealth Long Term Care services. Annuitant Name (Last, First, MI) Address (Street) Annuity Issuer (1) Name of person who owns the annuity (Last, First, MI) Social Security Number* Date of Birth City Purchase Date State Zip Code

Annuity Contract Number

(2) Name of person who owns the annuity (Last, First, MI) Social Security Number Date of Birth

*Personally identifiable information and Social Security Numbers is used only for the direct administration of the ForwardHealth program. Please indicate if any of the following statements describe your annuity. Check all that apply. The annuity is considered either: An individual retirement annuity [according to Sec.408 (b) of the Internal Revenue Code of 1986 (IRC)] A deemed Individual Retirement Account (IRA) under a qualified employer plan (according to Sec.408 (q) of the IRC) OR The annuity was purchased from proceeds from one of the following A traditional IRA (IRC Sec. 408a) Certain accounts or trusts which are treated as traditional IRAs [IRC Sec. 408 §(c)] A simplified retirement account [IRC Sec. 408 §(p)] A simplified employee pension [IRC Sec. 408 §(k)] A Roth IRA (IRC Sec. 408A) Other (please describe) Please include proof from your financial institution, employer or employer association of how you funded this annuity. The annuity is irrevocable and non-assignable. The annuity is actuarially sound. The annuity provides payments in approximately equal amounts, with no deferred or balloon payments.

ANNUITY INFORMATION - DISCLOSURE F-10192 (01/09)

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Have any transactions been made on this annuity on or after January 1, 2009? Check all that apply. Added to the principal of the annuity. (Check this box if funds were added to the annuity or if funds were rolled over from another source into the annuity.) Elective withdrawals made. "Elective withdrawals" means getting money out of the annuity that is not part of the regular payout schedule. Changed the way money is paid out of the annuity. What was the change? Date change made? Changed the annuity owner, payee or death beneficiary, including the transfer of ownership in whole or in part to a trust. Note: DO NOT check this box if the only change made to the annuity on or after January 1, 2009, was naming the Wisconsin Department of Health Services a death beneficiary. What was the action? Date of action? No transactions have been made on or after January 1, 2009.

I declare that, under penalty of perjury or false swearing, that all of the information I have provided is correct and complete to the best of my knowledge. SIGNATURE ­ Member/Applicant Date Signed SIGNATURE ­ Spouse or Parent/Guardian SIGNATURE ­ Authorized Representative Date Signed Date Signed

County or Tribal Agency Name and Address

Agency Worker

Telephone Number

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