WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10147 (07/08)
Eligibility ending: Case # Daily Rate $
WISCONSIN VETERANS HOME AT KING - MEDICAID REVIEW
Name Married Y N
Check yes or no for each income source listed below. List the gross income amount you receive each month for each of the following. If married, review spouse's income on CAF and make changes if necessary, and attach this form to the CAF.
Type of Income
Y Y Y Y Y N Income from a job
(including work therapy)
$ $ $
Y Y N N
Type of Income Amount
Social Security $ Retirement $ $ $
N Veterans N Self-Employment N Other (Type) N Other (Type)
Check yes or no for each asset below. Write in the value and, if jointly owned, the name of the joint owner.
Liquid Assets Value
Y Y Y Y N N N N Cash Checking Acct Life Insurance Other: $ $ $
Y Y $
N N N Savings Account Real Property Life Insurance
$ $ $
Y Y Y N N N Burial Insurance Irrevocable Burial Trust Other:
$ $ $ Y Y N N
Vehicle List all vehicle(s) owned.
Year Year Make Make Model Model Amount Owed $ Amount Owed $ Value $ Value $
Court-ordered Fees Do you make any support payments for persons living in another household or are you required by the court to pay guardian or attorney fees? Y N Type Amount $
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WISCONSIN VETERANS HOME AT KING - MEDICAID REVIEW F-10147 (07/08)
Y N If yes complete the following.
Do you have any private health insurance coverage? Premium Amount $ How Often Paid
Have you sold or given away any income or assets or put funds in a trust in the last 12 months? If yes, please describe Y N
By signing this form, you certify you understand the questions and statements on this application form. You understand the penalties for giving false information or breaking the rules. You certify, under penalty of perjury and false swearing, that all your answers are correct and complete to the best of your knowledge. You understand and agree to provide documents to prove what you have said. You understand that the Medicaid office may contact other persons or organizations to obtain the necessary proof of your eligibility and level of benefits. X SIGNATURE Applicant/Representative/Guardian/Power of Attorney/Conservator Date Signed
If recipient is married, please review the copy of the CAF with spouse, indicate changes and be sure CAF is then signed by the spouse.
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