Free 37113.pdf - Indiana

APPLICATION FOR THE RESIDENTIAL CARE ASSISTANCE PROGRAM
State Form 37113 (R3 / 3-01) / BAIS 0050

C O N F I D E N T I A L
CONFIDENTIALITY STATEMENT The personal information requested on this form will be used in the determination of your entitlement to or continued receipt of Residential Care Assistance administered by the Bureau of Aging and In-Home Services. Disclosure of the information requested is mandatory pursuant to the provisions of IC 12-10-6. Non-disclosure of the information requested will hamper and possibly prevent the delivery of assistance to you. All personal information collected on this form will be treated as confidential pursuant to applicable laws and regulations. SOCIAL SECURITY NUMBER Your Social Security number is being requested by this state agency pursuant to the provisions of IC 4-1-8-1. FOR USE BY THE COUNTY OFFICE OF FAMILY AND CHILDREN
CASE NUMBER Type Code Serial

Date of application (month, day, year)

ICES history screening

Received by: (name or initials of person completing this box)

Date one copy of application mailed to DDARS (month, day, year)

Other copy to be filed in case folder.

To the County Office of Family and Children of _____________________________ County:
1. I wish to apply for Residential Care Assistance 2. I am: (check all that apply) 2a. Race

RBA 3. My full name Mr. First is: Mrs. Ms.
4. I will live at or will be entering: (name of facility)

ARCH

65 years of age or over
Middle Last

Blind

Disabled
Maiden name (if applicable)

Date entered facility

County

Address

City

State

ZIP code

5. My mailing address is: City 6. Social Security number

the same as above; or different and is

Address

Telephone number ZIP code

State

Medicare claim number

Railroad retirement number

Veterans claim number

7. Date of birth (month, day, year) Place of birth (city or county)

VERIFICATION (For Use by the County Office of Family and Children) SOURCE, LOCATION AND DATE COMPLETED

Place of birth (state or country)

United States citizen Lawfully admitted for permanent residence

Yes Yes

No No

8. I have given away, sold, deeded, or transferred any items of value, such as money, land, buildings, shares of insurance, or bank accounts within the last five years. Yes No 9. Blind Applicants Only: I am blind within the meaning of the definition set forth in IC 12-7-2-21. Yes No

10. Disabled Applicants Only: I have a disability which has lasted or is expected to last twelve (12) months. Yes No

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C O N F I D E N T I A L
11. INCOME INFORMATION

I receive money. A. Supplemental Security Income B. Social Security C. Medical Assistance or Medicaid D. Veterans Benefits E. Railroad Retirement Type

Yes No If Yes, the money comes from: F. Pension L. Rental of Property G. Military Allotment M. Regular money from relatives H. Unemployment Compensation N. Other (describe) I. Support Payments J. Union Benefits K. Sick Benefits How Often?

VERIFICATION (For Use by the County Office of Family and Children) SOURCE, LOCATION AND DATE COMPLETED

Amount $ $ $ $ 12. EMPLOYMENT INFORMATION Employed Yes
Name of employer Address of employer If self-employed, state occupation How long employed?

No

If Yes, complete below:

Regular working hours From

To

Earnings before deduction each pay period

$
How often payed?

Daily Weekly

Every Other Week Twice a Month
Hourly wage

Monthly Other _________

Number of days worked each week Payroll deductions

Social Security Union Dues Employment Expenses Per Week:

$ Income Taxes Other ______________________
Transportation costs:

Drives a car to work one-way, ____________ miles Rides With Someone Bus Other _________________
Other employment expenses (uniforms, etc.)

$
Describe 13. I have:

A. Savings Account in Bank G. Other money in burial account in bank, with funeral director, or B. Checking Account in Bank with others (specify) __________ C. U.S. Savings Bonds __________________________ D. Stocks and Bonds E. Savings and Loan Association H. Other (describe) __________ F. Credit Union Shares __________________________ OWNED BY TYPE AMOUNT LOCATION Owned Jointly Myself With Others $ $ $ $ $
14. LIFE INSURANCE

I am insured. Name of Company Policy Number Date Issued Face Value Cash Value Owner of Policy
Address Amount of taxes

Yes

No

If Yes, complete below:

15. I own real property (land or buildings) in which I am not living.

Yes

No

Insurance

Monthly payment

$
Monthly income

$
Balance owed

$ $ Page 2

$

C O N F I D E N T I A L
Yes 16. I own personal property. Type Make No If Yes, complete below: Model Year VERIFICATION (For Use by the County Office of Family and Children) SOURCE, LOCATION AND DATE COMPLETED

17. MEDICAL INFORMATION I have health coverage that meets all or part of my medical needs. Yes No If Yes, complete below: Medicare Part A CHAMPUS Medicare Part B CHAMPVA Workman's Compensation Veterans Administration Other (describe) ______________________________________ HEALTH INSURANCE Name of Company: Policy Number Date Coverage Effective: Hospitalization? Major Medical? Cancer Policy Only?

Yes Yes Yes

No No No

Yes Yes Yes

No No No

18. EACH APPLICANT MUST READ THE FOLLOWING POINTS AND PUT AN "X" IN EACH BOX TO SHOW THESE STATEMENTS

ARE UNDERSTOOD AND AGREES TO THEIR PROVISIONS. I understand that I will be asked to provide proof of the information which I have given and I agree to help the County Office of Family and Children obtain the necessary verifications. I also understand that a person who receives assistance by giving false information may be criminally prosecuted under applicable State law. I agree to let the County Office of Family and Children know within seven (7) days of any change in my income or resources and any other changes that might affect my eligibility for assistance. I agree to any examinations necessary to establish my eligibility for Room and Board Assistance or Assistance to Residents in County Homes. I authorize any physician, hospital, or other provider of care to release any medical information about me, if requested by the County Office of Family and Children. I agree to file for any benefits for which I may be eligible. I agree to contribute my personal income, minus the personal needs amount, toward my room and board. I authorize the release of medical or other information acquired by the Medicare Carrier and/or Intermediary under the Title XVIII Program (Medicare) to the extent necessary to process any current or future Medicaid claim. I understand and acknowledge that any assistance granted me becomes a lien against any real property I now own or subsequently acquire, that a notice of said lien will be filed in the office of the County Recorder, and that such assistance becomes a preferred claim against my estate.

STATE OF COUNTY OF
in which oath is administered

I do solemnly swear (or affirm) that all statements made in the foregoing application are true and correct to the best of my knowledge and belief. (If applicant affirms, the "swear" should be crossed out.)
Signature of applicant, legal guardian, or interested person

Signature of witness (if signature is by "X")

Address of witness

Signature of witness (if signature is by "X")

Address of witness

Subscribed and sworn to before me and execution acknowledged this ______ day of ____________________________, _____.
Signature of person administering oath Title of person administering oath

My commission expires (month, day, year)

My authorization expires (month, day, year)

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