Whqt services qre you requesting?

#:ffi ;,. ;:#: ;ffi;H{d l*li{**,"

1

I am a resident of Arkansas: Yes

ffi

No

l]
First

2. I am.

65 years of age or older

gtind

Disabteo

f]

Myfuilnameis:Cee,*'dh---_-foni(uMRaceVU-_sex-F
Last
rMy

Middie

currenr address

is ao:tr 3. !|illq, 755 lauaco

PhysicalAddre*su City

fr.Kk, ..- ?*9!lState State Zip

"$*A -ast'rn:
County

*--.*,a

Mailrng AddrgLs (P

i-t{* +, 45q 0 8ox)

Mailing Address

City
Ciry

eggt
Zip
Zip

S&as{,q.,t
County

My forrner address was:

State

Counly

I have lived at my cunent address

6
7

lar f5

years.

_179_:C*t:Za7l570*-:.5c ^ Ll ttlg 57o so 4tua 4 Medicare Number Social Security Number

My tetephone number

is

6. I was born

on:

,.r

"

lq

fq

Yeer

City or County

Railroad Ret Number

o

VA Claim Number

State or Country

I am a U.S. Citizen; Yes

ffi

No

E
n

lam a lawfully admitted Alien: Yes

No

10.

lam:

Married

Separated

Widowed

Dir,trced

t]

Single

Complete Questions 11
My spouse's name is;
Last

- 15 ONLY if you have a Spouse

First Middle

12
13"

My spouse s address is
Street or Route No. City

Srate

Zip

County

My spouse's telePhone number is

14. My spouse was bom on:

Month Day

Year

Spo,,seb
oco"777 (R 01/10)
Page 1 ol
4

Soc.S.;N"

"*

Spouse's Medicare No.

Spouse s Railroad Ret. No

Spouse's VA Claim No

16 land my spouse

received)

have income {rom the following: (Check (./)Yes or No. lf yes enter the amount arrd how oflen the MysELF
MY SPOUSE AMOUNT

in.or.

SOURCE OF INCOME

Money From Trusts Mineral Rights/Oil Leases

Cash Contributrons

Worl..er's Compen93lion

Fanning/Seli Employrnent
Deposits by Others for Me

17.
18.

I or my spouse have received SSI in the past:

I I

Yes Yes

r'roK
r.ro

lf Yes, when

or my spouse expect a change in incorne:

lf Yes, explain

19.

Yesl I No or my spouse own a home lf yes, my home is occupied by my spouse and/or dependent relatives
Address of Home

Yes L-l
itv Value

No

I or my spouse formerly owned homes in

Cily, Counly end State
,

qn
County and Slate

tu

I or my spouse own real property, (land or buildings), other than my home If yes, complete the following:
Ac.idress ol

Yes

fl

NoM

Prope(y

Equitv Value

Address ol Properly

Equily Valtre

I or my spouse formeriy owned real property other than my home in

Citv,
LI

County aud State

To Whonr

I I

or my spouse have sold/deeded/given away a home or other real prcperty:

or my spouse retain life estate, dower, curtesy, inhentance or other interest in a home or other prope(y
Iype of Inleresi
\/alue

t1

Locaiion ol Propertv (Cilv, Courrty, State)

DCO-777 (R.01/10) Page 2 of 4

23,

I or rny spouse ovvn personal property such as cars, trucks, tractors or famr machinery, Irailers boats, etc,: (lf more than three, please list on a separate sheet)
Item

(l/ako, Model, and Year)

Equily \ralue Equily Value

Equity Vslue
)

Item (lv1ake, Model, and Year)

Iterrr (Make. Model,

antj Year)

L+.

Yes

I or my spouse own Iivestock (cattle, poultry, cat{lsh minnows. cnckets, worms, etc lf yes, complete the lollowrng:

tl

No

Type of Livestock and Nurnber Owned

I

Valtre

of joint owner, if any.)

or my spouse have the following assets. (Check lrl) Yes or No. lf yes. enter the amounUvalue, tocation of the asset, and narne

TYPE
Cash

YES

NO

AMTI/ALUE

LOCATION OF ASSET

Checkino Account Savinqs Account Other Savinqs (Ce(ificates, eh.) Promissory Notes
Stocks Bonds

\/ r<

\Z

,/ ,{

e\k=B

o-:.*l-

l)^{:r*.

NAME OF JOINT OWNER

t.r.^oa

Patient Fund Account Mortgaqe Eurial PloUCrvot Burial Funds/l nsurance Life lnsurance
Trusts

\,/

w
1/.

)rX.l\r

,(

)crn (er.ror.eLle

\-

Other

26. lor my spouse ha-ve additional income andlor property

Yes
27

[]

rrro

(realor personal)lhat I was unable to list under rtems 16 through 23 lf yes, record your answeils)'orr a separate sheel

Yes

or my spouse.have other resources (real or personal properly) that are berng hetd {or me by a nother individual No lf yes, complete the following:

Type of Resource Type of Resource

Location of Resource Location of Resource

AmUValue
AmUValuts

28I or my spouse_have
A

ical insurance coverage. Yes

{

G.

Name and Address of lnsurance Company

r#' ,ED
J

6f4ilej!5rorrowr Y",/W31+722.

n'

Policv No

29.
30
31

I have unpaid medical expenses from the past three (3)

monlhs. yes I

No Yes

l, or someone in my household, would like to learn to read, or lo read better

Do you have Long Term Care lnsurance?

tr

ruoH

Yes

ru.

DC0-777 (R 01/10) P:ge 3 of 4

I understand tha( I must help establish my elrgibilrty by providing as much of the requested information as I can. I authortze the oepa(meni o{ Human Services to make any investigation conc,erning me and/or my spouse necessary to establish my elgibility lor assistance, I undersland thal no person may be denied long term care assistance or olher Medicaid assistance on the grounds of race, color, sex. national origin or disabilitY. lunderstand that lmay request a hearing be{ore the state agency represenlative if a decision is nol reached on my ffise within the appropriate time limit or it ldisagree uvtth the dectsion reeched. lagree to notfy the Deparhent o[ Human Services within 10 days if lor my spouse receive additional income acqurre or dispose ol property or if any oUter changes orcur in my circumstances, I authorize the Department of Human Services to examine all records of mine, or records of those receivrng or having received tr4edicaid benefils through me, for the purpose of investigaing whether or not any person may have cornnri6ed Medicaid fraud or for use in any legal, administrative or ludicial proceeding, I understand liat I must pro\'lde my Social Security Number as a condition ol my eligibi[ty, and I undersland that this nurnber nray be used by the Agency without rny express permission in a computer match to obtain informalion relatrve to my eligibilily for assistance fronr the Social Security Adrninistration, Departrnentof Workforce Services, lnternal Reventre Services, or other agencies AS$IGNMENT OF MEDICAL SUPPORI, I authorize any holder ol medical or other inlorma[on about me to release infornration needed for a Medicaid claim to DHS i further authorize release of any in[orrnation to other parties who may be lrable for rly rnedicai expeilseS. As an eligibility conditron lautomalically assign rny rightto any settlement, ludgement, or awarcl which rnay be obtained againsl anythirdpartytoDHStothefull extentofanyamountwhichispaidbyDHsonmybehalf. lauhorizeandrequestthatfurrcjs. settlernent or other payments firade by or on behalf of third per(ies, inoludtng tortfeasors or insurers arising out of a Medicaid claim, be paid directly to DHS My application for Medicaid benefits shall in itself constitute an assignment by operation of law and shalt be considered a statutory lien of any settlement. jlrdgement, or award received by me from a third parly, A third parry is any person, ontity, institution, organization or other source which rnay be liable for iniury, disease, disabilrty or death sustained by me or oihers nanred herein. irrcJuding estates of said individuals I aiso assign all rights in any sefllemeni made by me ot on my behalt ari5ing out of any clairn to the exlent of medical expenses paid by DHS, whether or not a po(ion of such settJement is designated for medical expenses. Any such funds received by me shall be paid to DHS. A copy of this authoriradon may be used in pioce ol the originel lunderstand the requirement to disclose, in my application for Long Term Care services, information regarding any rnterest that I or my comrnunity spouse may have in an annuity. I understand the requirernentto name the state as a romainder beneficiary in which lor my spouse is the annuitant. lf you have questions or problems regarding your application or care, please call your State Long Term Care Ombudsman at 501,682-8S52 IMPORTANT ESTATE RECOVERY NOTICE: lf you receive Medicaid in a nursing facility, ICFIMR facility, or under a hotne and community based waiver program, he totalsrnounl0f the Medicaid benefits paid on your behalf will be a debt lo DHS and may be recovered from your state or from the grantee of a beneficiary deed after your death Your estate is the pioperty you o\{n atthe trme otyour death DHS will not make a claim against yorrr estate while you are living DHS will not make a claim against your eslate after your death if your spouse is still living, or if you have dependent children under age 21 or blind or disabled children DHS will collect the debl, if any, by filirrg a claim irr your eslate

Collectionmaynotbemadeifit isnot cost effoctivetoDHSorifyourheirsapplyforahardshipwaiverafteryourdeath Ahgrd5hipqrsy exisl iF the estate property is the only source of income for your heirs, if that incorne is limrted, 0r it there are otlrer conrpelling
circumstances.

CERTIFICATION: I H,AVE READ IHE ABOVE STATEMENTS AND I AGREE TO THEIR PROVISIONS.
FOR LONG TERM CARE FACILITY RECIPIENTSIAPPLICANTS 0NLY: After reviewing the alternatjves Io nursrrrq facrlity placement available through he Depsrtmentof HUman ServiCes, lunderstand that lam choosing to be served in a nursing facility I understand that if lam admitted to a nursing facility based on conditional Medicaid approval and nry Medicaid case is denied, l, or my family, will be responsible for any indebtedness while in the nursing facility I understand that this form is signed subject lo psnalties for perjury, I understarrd thal ii I receive assislance to which I am not entitled as a rosult of withholding informatjoll or providing inaccurate inlormation, such assisl ill be subioct lo recovery by the DepBrtmenI of Hurrran Services and I rnay be sublect to prosecution for fraud and

Wilness (if signed by mark)iDate

Dl/bl tZ
Address of Wilnessffelephone Number
Date

477- 4571b07?
Telephone Number

AlBq So jk,t
Name of Person Who Helped Complete Form/Date
oQa-777 (R o1l10)

Guardian or Aulhonzed Rep. s Address

45,

fa,oirut-

AlLflqql

--.--Pagedof4

Arkansas Department of Human Services

Division of County Operations DISPOSAL OF ASSETS DISCLOSURE
Si necesita este formulario en Espaflol, llame al l-800-482-8988 y pida la versi6n en Espafiol

lf you need this material in a different format, such as large print, contact your DHS county Office.

Medicaid rules require the complete disclosure of all asset transfers (real or personal property transfers) made by yourself or your spouse since 02-08 -2006. Al1 such transfers must be documented by the local Human Services Office to determine your eligibility for Medicaid assistance. Read each part of this form carefully to determine parts which apply to you.You must complete and sign Part A or Part B. Please complete another form to report additional transfers. PART

A.

ASSETS TRANSFERRED
a trust or

tr
tr

I (or my spouse) established

and/

annuity on
(Date)

Please provide a copy of your trust

or annuity documents.

I (or my spouse) have sold, transfeffed, assigned, or given away the following
accounts, securiti real or Transferred to
(Name)

assets (cash, checking

, etc. since 02-08 -2006:

Provide the address and telephone number below for the person that received the item. Address
(Please use an additional sheet ofpaper ifneeded).

Telephone Number

This statement is true to the best of my knowledge, and I understand that should I give a false statement, I may be subject to criminal prosecution. I also understand that I will be liable for any overpayments made on my behalf by the Arkansas Medicaid program due to my misrepresentation of fact(s).
Signature

PART

B. NO ASSETS
I (or my

TRANSFERRED

spouse) have not established a trust or annuity, and have not sold, transferred, assigned, or given away any assets (cash, checking accounts, savings accounts, securities, real or personal property, etc.) since 02-08-2006. This statement is true to the best of my knowledge, and I understand that should I give a false statement, I may be subject to criminal prosecution. I also understand that I will be liable for any overpayments made on my behalf by the Arkansas Medicaid program due to my misrepresentation of fact(s).

Signature

-t?/te

//3

DCO-727 (R.02l10)
Page 1 of2