Form MC210 B "Supplement to Statement of Facts (Pickle Eligibility Determination)" - California

What Is Form MC210 B?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2007;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form MC210 B by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form MC210 B "Supplement to Statement of Facts (Pickle Eligibility Determination)" - California

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State of California—Health and Human Services Agency
D epartment of Health Care Services
SUPPLEMENT TO STATEMENT OF FACTS
(PICKLE ELIGIBILITY DETERMINATION)
Case name
Case number
Applicant’s name
1.
Do you (separately, or jointly with another person) own household goods or personal items, including a musical instrument and/or
recreational vehicle valued at more than $500 per item?
Yes
No
If yes, list below:
Owned
Owned
Jointly
Separately
Amount Owed
Item
Total Value of Each Item
on Each Item
(Check One.)
a.
Is recreational vehicle used as your principal residence?
Yes
No
b.
If yes, is it your only source of transportation?
Yes
No
2.
Do you own one or more vehicles, including boats, motorcycles, snowmobiles, etc?
Yes
No
If yes, list below.
Blue-book
Amount
Vehicle
Value
Owed
If yes, list vehicle(s) which is necessary for self-support:
3.
Do you have a retirement account, such as a KEOGH or IRA account?
Yes
No
If yes, amount on deposit $
Account number(s):
Name of financial institution
Address of financial institution
City
State
ZIP code
4.
Do you have a burial fund (not burial insurance or contract with a funeral home)?
Yes
No
If yes, amount on deposit $
Account number(s):
Name of financial institution
Address of financial institution
City
State
ZIP code
Applicant/representative signature
Date
MC 210 B (05/07)
State of California—Health and Human Services Agency
D epartment of Health Care Services
SUPPLEMENT TO STATEMENT OF FACTS
(PICKLE ELIGIBILITY DETERMINATION)
Case name
Case number
Applicant’s name
1.
Do you (separately, or jointly with another person) own household goods or personal items, including a musical instrument and/or
recreational vehicle valued at more than $500 per item?
Yes
No
If yes, list below:
Owned
Owned
Jointly
Separately
Amount Owed
Item
Total Value of Each Item
on Each Item
(Check One.)
a.
Is recreational vehicle used as your principal residence?
Yes
No
b.
If yes, is it your only source of transportation?
Yes
No
2.
Do you own one or more vehicles, including boats, motorcycles, snowmobiles, etc?
Yes
No
If yes, list below.
Blue-book
Amount
Vehicle
Value
Owed
If yes, list vehicle(s) which is necessary for self-support:
3.
Do you have a retirement account, such as a KEOGH or IRA account?
Yes
No
If yes, amount on deposit $
Account number(s):
Name of financial institution
Address of financial institution
City
State
ZIP code
4.
Do you have a burial fund (not burial insurance or contract with a funeral home)?
Yes
No
If yes, amount on deposit $
Account number(s):
Name of financial institution
Address of financial institution
City
State
ZIP code
Applicant/representative signature
Date
MC 210 B (05/07)