LONG TERM ASSISTANCE WAVER

The following items are needed from you and your spouse to determine if you are eligible for Long-Term Care Medical Assistance: □ Federal Tax Returns for the current year and the preceding four years (please include all forms and schedules). A Record of Account can be obtained from the IRS free of charge by calling 1-800-908-9946 if your Federal tax returns cannot be located. □ Bank and Financial statements on all accounts owned and co-owned: □ Current Month (month of application) □ Previous Month (month prior to application) □ The last five years of the anniversary month of the application □ Current statement of retirement accounts □ Current statement of IRA or Keogh Accounts □ Current statements of: □ Stocks □ Bonds □ Money Market Funds □ Mutual Funds, Treasury, or Other Notes □ Certificates □ Current gross monthly income from all sources including: □ VA Pensions □ Railroad Retirement □ Pensions □ Annuities □ Face and cash value of Life Insurance policies (current annual statement) □ Current statement for burial accounts □ Burial Plot Deeds □ Life Estate Deeds □ Promissory Notes □ Mortgage Notes and Mortgage Deeds □ Trusts (including appendices, schedules, annual accountings, and amendments for the past five years) □ Private Health Insurance Cards including Medicare (copy of both sides) □ Health Insurance premium amounts □ Power of Attorney or Legal Guardianship Documents (if any)