Form MC604 IPS ARM "Additional Income and Property Information Needed for Medi-Cal" - California (Armenian)

Form MC604 IPS ARM is a California Department of Health Care Services form also known as the "Additional Income And Property Information Needed For Medi-cal". The latest edition of the form was released in May 1, 2014 and is available for digital filing.

Download an up-to-date Form MC604 IPS ARM in PDF-format down below or look it up on the California Department of Health Care Services Forms website.

Download Form MC604 IPS ARM "Additional Income and Property Information Needed for Medi-Cal" - California (Armenian)

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State of California Health and Human Services Agency

Department of Health Care Services

§MEDI-CAL¦-ÆÜ ²ÜÐð²ÄºÞî Èð²òàôòÆâ îºÔºÎàôÂÚàôÜÜºð

ºÎ²ØàôîÆ ºì êºö²Î²ÜàôÂÚ²Ü Ø²êÆÜ

Ø»Ýù ¹»é ·Ý³Ñ³ïáõÙ »Ýù §Medi-Cal¦-Ç Ò»ñ Çñ³í³ëáõÃÛáõÝÁ, ¨ Ù»½ Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñ »Ý ³ÝÑñ³Å»ßï:

ÊÝ¹ñáõÙ »Ýù å³ï³ëË³Ý»É ëïáñ¨ ïñí³Í Ñ³ñó»ñÇÝ` Ò»ñ ÁÝï³ÝÇùÇ ³Ý¹³Ù Ñ³Ý¹Çë³óáÕ Ûáõñ³ù³ÝãÛáõñ ³ÝÓÇ

Ù³ëÇÝ: ¸³ Ý»ñ³éáõÙ ¿ Ò»½, Ò»ñ ÏÝáçÁ Ï³Ù ³ÙáõëÝáõÝ ¨ Ò»½ Ñ»ï µÝ³ÏíáÕ ÙÇÝã¨ 21 ï³ñ»Ï³Ý »ñ»Ë³Ý»ñÇÝ Ï³Ù

ÁÝï³ÝÇùÇ áñ¨¿ ³ÛÉ ³Ý¹³ÙÇ, áñÁ Å³Ù³Ý³Ï³íáñ³å»ë Ò»ñ ï³ÝÁ ãÇ µÝ³ÏíáõÙ, ûñÇÝ³Ï` ¹åñáóáõÙ ¿, ³ßË³ï³ÝùÇ

µ»ñáõÙáí µ³ó³Ï³ÛáõÙ ¿ Ï³Ù ÑÇí³Ý¹³ÝáóáõÙ ¿ ·ïÝíáõÙ:

¶áñÍÇ ³ÝáõÝÁ`

¶áñÍÇ Ñ³Ù³ñÁ`

²ßË³ïáÕÇ ³ÝáõÝÁ`

²ßË³ïáÕÇ Ñ»é³ËáëÇ Ñ³Ù³ñÁ`

àõÕ³ñÏ»Éáõ ³Ùë³ÃÇíÁ`

ì»ñ³¹³ñÓñ»ù ³Ûë Ã»ñÃÇÏÁ ÙÇÝã¨`

ÀÝï³ÝÇùÇ Ù³ëÇÝ å³Ñ³ÝçíáÕ Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñ

Ð»ï¨Û³É Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñÝ ³ÝÑñ³Å»ßï »Ý: ä³ï³ëË³Ý»ù ÙÇ³ÛÝ ³ÛÝ ¹»åùáõÙ, »Ã» ³Ûë ¿çáõÙ Ýßí³Í

Ñ³ñó»ñÁ í»ñ³µ»ñáõÙ »Ý Ò»½ Ï³Ù Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³ÙÇ:

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ³Ûëï»Õ, »Ã» ¸áõù Ï³Ù Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù å³ßïáÝ³å»ë ³ÙáõëÝ³ó³Í ¿, µ³Ûó

Ý»ñÏ³ÛáõÙë ÏÝáçÇó Ï³Ù ³ÙáõëÝáõó ³é³ÝÓÇÝ ¿ ³åñáõÙ:

ºÃ» Ýß³Ý »ù ¹ñ»É í³Ý¹³ÏáõÙ, ËÝ¹ñáõÙ »Ýù Ýß»É Ò»ñ ÁÝï³ÝÇùÇ ³ÛÝ ³Ý¹³ÙÇ ³ÝáõÝÁ, áñÝ Çñ ÏÝáçÇó Ï³Ù

³ÙáõëÝáõó ³é³ÝÓÇÝ ¿ ³åñáõÙ:

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ³Ûëï»Õ, »Ã» ¸áõù Ï³Ù Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù ËáñÃ ÍÝáÕ ¿:

ºÃ» Ýß³Ý »ù ¹ñ»É ³Ûë í³Ý¹³ÏáõÙ, ËÝ¹áõÙ »Ýù Ýß»É`

ËáñÃ ÍÝáÕÇ ³ÝáõÝÁ`

³Û¹ ËáñÃ ÍÝáÕÇ »ñ»Ë³Ý»ñÇÝ`

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ³Ûëï»Õ, »Ã» Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù »ñ»Ë³ ¿, áñÇÝ ËÝ³ÙáõÙ ¿ á°ã Ã» ÍÝáÕÁ, ³ÛÉ Ò»ñ

ï³ÝÁ µÝ³ÏíáÕ áñ¨¿ ³½·³Ï³Ý:

ºÃ» Ýß³Ý »ù ¹ñ»É ³Ûë í³Ý¹³ÏáõÙ, ËÝ¹áõÙ »Ýù Ýß»É`

ËÝ³ÙáÕ ³½·³Ï³ÝÇ ³ÝáõÝÁ`

ËÝ³ÙíáÕ »ñ»Ë³Ý»ñÁ`

Page 1 of 7

MC 604 IPS ARM (5/14)

State of California Health and Human Services Agency

Department of Health Care Services

§MEDI-CAL¦-ÆÜ ²ÜÐð²ÄºÞî Èð²òàôòÆâ îºÔºÎàôÂÚàôÜÜºð

ºÎ²ØàôîÆ ºì êºö²Î²ÜàôÂÚ²Ü Ø²êÆÜ

Ø»Ýù ¹»é ·Ý³Ñ³ïáõÙ »Ýù §Medi-Cal¦-Ç Ò»ñ Çñ³í³ëáõÃÛáõÝÁ, ¨ Ù»½ Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñ »Ý ³ÝÑñ³Å»ßï:

ÊÝ¹ñáõÙ »Ýù å³ï³ëË³Ý»É ëïáñ¨ ïñí³Í Ñ³ñó»ñÇÝ` Ò»ñ ÁÝï³ÝÇùÇ ³Ý¹³Ù Ñ³Ý¹Çë³óáÕ Ûáõñ³ù³ÝãÛáõñ ³ÝÓÇ

Ù³ëÇÝ: ¸³ Ý»ñ³éáõÙ ¿ Ò»½, Ò»ñ ÏÝáçÁ Ï³Ù ³ÙáõëÝáõÝ ¨ Ò»½ Ñ»ï µÝ³ÏíáÕ ÙÇÝã¨ 21 ï³ñ»Ï³Ý »ñ»Ë³Ý»ñÇÝ Ï³Ù

ÁÝï³ÝÇùÇ áñ¨¿ ³ÛÉ ³Ý¹³ÙÇ, áñÁ Å³Ù³Ý³Ï³íáñ³å»ë Ò»ñ ï³ÝÁ ãÇ µÝ³ÏíáõÙ, ûñÇÝ³Ï` ¹åñáóáõÙ ¿, ³ßË³ï³ÝùÇ

µ»ñáõÙáí µ³ó³Ï³ÛáõÙ ¿ Ï³Ù ÑÇí³Ý¹³ÝáóáõÙ ¿ ·ïÝíáõÙ:

¶áñÍÇ ³ÝáõÝÁ`

¶áñÍÇ Ñ³Ù³ñÁ`

²ßË³ïáÕÇ ³ÝáõÝÁ`

²ßË³ïáÕÇ Ñ»é³ËáëÇ Ñ³Ù³ñÁ`

àõÕ³ñÏ»Éáõ ³Ùë³ÃÇíÁ`

ì»ñ³¹³ñÓñ»ù ³Ûë Ã»ñÃÇÏÁ ÙÇÝã¨`

ÀÝï³ÝÇùÇ Ù³ëÇÝ å³Ñ³ÝçíáÕ Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñ

Ð»ï¨Û³É Éñ³óáõóÇã ï»Õ»ÏáõÃÛáõÝÝ»ñÝ ³ÝÑñ³Å»ßï »Ý: ä³ï³ëË³Ý»ù ÙÇ³ÛÝ ³ÛÝ ¹»åùáõÙ, »Ã» ³Ûë ¿çáõÙ Ýßí³Í

Ñ³ñó»ñÁ í»ñ³µ»ñáõÙ »Ý Ò»½ Ï³Ù Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³ÙÇ:

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ³Ûëï»Õ, »Ã» ¸áõù Ï³Ù Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù å³ßïáÝ³å»ë ³ÙáõëÝ³ó³Í ¿, µ³Ûó

Ý»ñÏ³ÛáõÙë ÏÝáçÇó Ï³Ù ³ÙáõëÝáõó ³é³ÝÓÇÝ ¿ ³åñáõÙ:

ºÃ» Ýß³Ý »ù ¹ñ»É í³Ý¹³ÏáõÙ, ËÝ¹ñáõÙ »Ýù Ýß»É Ò»ñ ÁÝï³ÝÇùÇ ³ÛÝ ³Ý¹³ÙÇ ³ÝáõÝÁ, áñÝ Çñ ÏÝáçÇó Ï³Ù

³ÙáõëÝáõó ³é³ÝÓÇÝ ¿ ³åñáõÙ:

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ³Ûëï»Õ, »Ã» ¸áõù Ï³Ù Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù ËáñÃ ÍÝáÕ ¿:

ºÃ» Ýß³Ý »ù ¹ñ»É ³Ûë í³Ý¹³ÏáõÙ, ËÝ¹áõÙ »Ýù Ýß»É`

ËáñÃ ÍÝáÕÇ ³ÝáõÝÁ`

³Û¹ ËáñÃ ÍÝáÕÇ »ñ»Ë³Ý»ñÇÝ`

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ³Ûëï»Õ, »Ã» Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù »ñ»Ë³ ¿, áñÇÝ ËÝ³ÙáõÙ ¿ á°ã Ã» ÍÝáÕÁ, ³ÛÉ Ò»ñ

ï³ÝÁ µÝ³ÏíáÕ áñ¨¿ ³½·³Ï³Ý:

ºÃ» Ýß³Ý »ù ¹ñ»É ³Ûë í³Ý¹³ÏáõÙ, ËÝ¹áõÙ »Ýù Ýß»É`

ËÝ³ÙáÕ ³½·³Ï³ÝÇ ³ÝáõÝÁ`

ËÝ³ÙíáÕ »ñ»Ë³Ý»ñÁ`

Page 1 of 7

MC 604 IPS ARM (5/14)

Ø»½ ï»Õ»ÏáõÃÛáõÝÝ»ñ ïñ³Ù³¹ñ»ù Ò»ñ »Ï³ÙáõïÇ ¨ Í³Ëë»ñÇ Ù³ëÇÝ

Ø»½ ï»Õ»ÏáõÃÛáõÝÝ»ñ ïñ³Ù³¹ñ»ù Ò»ñ »Ï³ÙáõïÇ ¨ Í³Ëë»ñÇ Ù³ëÇÝ, áñáÝù Ï³åí³Í »Ý Ò»½, Ò»ñ ÏÝáç Ï³Ù

³ÙáõëÝáõ ¨ Ò»½ Ñ»ï µÝ³ÏíáÕ ÙÇÝã¨ 21 ï³ñ»Ï³Ý »ñ»Ë³Ý»ñÇ Ï³Ù ÁÝï³ÝÇùÇ áñ¨¿ ³ÛÉ ³Ý¹³ÙÇ Ñ»ï, áñÁ

Å³Ù³Ý³Ï³íáñ³å»ë Ò»ñ ï³ÝÁ ãÇ µÝ³ÏíáõÙ, ûñÇÝ³Ï` ¹åñáó Ñ³×³Ë»Éáõ, ³ßË³ï³ÝùÇ Ï³Ù ÑÇí³Ý¹³ÝáóáõÙ

·ïÝí»Éáõ å³ï×³éáí:

ºÏ³ÙáõïÁ

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ²Ûá Ï³Ù àã í³Ý¹³ÏáõÙ, »Ã» Ò»ñ ÁÝï³ÝÇùÇ ³Ý¹³ÙÝ»ñÇó áñ¨¿ Ù»ÏÁ ëïáñ¨ Ýßí³Í

ï»ë³ÏÇ »Ï³Ùáõï ¿ ëï³ÝáõÙ:

Üß³Ý ¹ñ»ù »Ï³ÙáõïÇ Ûáõñ³ù³ÝãÛáõñ ï»ë³ÏÇ ¹ÇÙ³óÇ í³Ý¹³ÏáõÙ:

²Ý³ßË³ïáõÝ³ÏáõÃÛ³Ý Ýå³ëïÝ»ñ

²Ûá

àã

ì»ï»ñ³ÝÝ»ñÇ Ýå³ëïÝ»ñ

²Ûá

àã

ºñ»Ë³ÛÇ ³åñáõëï³¹ñ³Ù

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àã

Üí»ñÝ»ñ

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ºÃ» í»ñÁ Ýßí³ÍÝ»ñÇó áñ¨¿ Ù»ÏÇÝ ²Ûá »ù å³ï³ëË³Ý»É, ËÝ¹ñáõÙ »Ýù ³Ûë Ã»ñÃÇÏÇ Ñ»ï »Ï³ÙáõïÇ ³å³óáõÛó

áõÕ³ñÏ»É: ²å³óáõÛó Ï³ñáÕ »Ý Ñ³Ý¹Çë³Ý³É Ñ»ï¨Û³É ÷³ëï³ÃÕÃ»ñÁ. §Social Security Administration¦-Çó, §Veteran’s

Administration¦-Çó §Employment Development Department¦-Çó ëï³ó³Í Ý³Ù³ÏÝ»ñÁ Ï³Ù Ñ³Ûï³ñ³ñáõÃÛáõÝÝ»ñÁ,

»ñ»Ë³ÛÇ ³åñáõëï³¹ñ³ÙÇ í»ñ³µ»ñÛ³É ¹³ï³ñ³ÝÇ áñáßáõÙÝ»ñÁ ¨ ïíÛ³É »Ï³ÙáõïÇ Ù³ëÇÝ ÏáÝÏñ»ï

ï»Õ»ÏáõÃÛáõÝÝ»ñ å³ñáõÝ³ÏáÕ ³ÛÉ ·ñ³íáñ ÷³ëï³ÃÕÃ»ñ:

Ì³Ëë»ñÁ

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ²Ûá Ï³Ù àã í³Ý¹³ÏáõÙ, »Ã» Ò»ñ ÁÝï³ÝÇùÇ ³Ý¹³ÙÝ»ñÇó áñ¨¿ Ù»ÏÁ Ï³ñáÕ ¿ ëïáñ¨

Ýßí³Í ï»ë³ÏÇ Í³Ëë»ñÁ Ï³ï³ñ»É:

Üß³Ý ¹ñ»ù Ûáõñ³ù³ÝãÛáõñ ï»ë³ÏÇ Í³ËëÇ ¹ÇÙ³óÇ í³Ý¹³ÏáõÙ:

ºñ»Ë³Ý»ñÇ ³åñáõëï³¹ñ³ÙÇ í×³ñáõÙ

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²ÛÉ Ï³ñ·Ç ³å³Ñáí³·ÝÇ ÙáõÍáõÙÝ»ñ

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§Medicare¦-Ç ³å³Ñáí³·ÝÇ ÙáõÍáõÙÝ»ñ

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ºñ»Ë³ÛÇ ËÝ³ÙùÇ Ñ»ï Ï³åí³Í Í³Ëë»ñ

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â³÷³Ñ³ë ³ÝÓÇ ËÝ³ÙùÇ Ñ»ï Ï³åí³Í Í³Ëë»ñ

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ÎñÃ³Ï³Ý Í³Ëë»ñ

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ºÃ» í»ñÁ Ýßí³ÍÝ»ñÇó áñ¨¿ Ù»ÏÇÝ ²Ûá »ù å³ï³ëË³Ý»É, ËÝ¹ñáõÙ »Ýù ³Ûë Ã»ñÃÇÏÇ Ñ»ï ïíÛ³É Í³ËëÇ ³å³óáõÛó

áõÕ³ñÏ»É: ²å³óáõÛó Ï³ñáÕ »Ý Ñ³Ý¹Çë³Ý³É Ñ»ï¨Û³É ÷³ëï³ÃÕÃ»ñÁ. »ñ»Ë³ÛÇ ³åñáõëï³¹ñ³ÙÇ í»ñ³µ»ñÛ³É

¹³ï³ñ³ÝÇ áñáßáõÙÝ»ñÁ, áõëÙ³Ý í³ñÓÇ Ù³ëÇÝ Í³ÝáõóáõÙÝ»ñÁ, §Medicare¦-Ç Ï³Ù ³ÛÉ ³å³Ñáí³·ñ³Ï³Ý

ÁÝÏ»ñáõÃÛ³Ý ÏáÕÙÇó áõÕ³ñÏí³Í Ý³Ù³ÏÝ»ñÁ, ³åñ³Ýù³·ñ»ñÁ Ï³Ù ëï³ó³Ï³ÝÝ»ñÁ ¨ ïíÛ³É Í³ËëÇ Ù³ëÇÝ

ÏáÝÏñ»ï ï»Õ»ÏáõÃÛáõÝÝ»ñ å³ñáõÝ³ÏáÕ ³ÛÉ ·ñ³íáñ ÷³ëï³ÃÕÃ»ñ:

Page 2 of 7

MC 604 IPS ARM (5/14)

Ø»½ ï»Õ»ÏáõÃÛáõÝÝ»ñ ïñ³Ù³¹ñ»ù Ò»ñ ë»÷³Ï³ÝáõÃÛ³Ý ¨ ·áõÛùÇ Ù³ëÇÝ

ÊÝ¹ñáõÙ »Ýù Ýß³Ý ¹Ý»É ²Ûá Ï³Ù àã í³Ý¹³ÏáõÙ, »Ã» Ò»ñ ÁÝï³ÝÇùÇ ³Ý¹³ÙÝ»ñÇó áñ¨¿ Ù»ÏÁ ëïáñ¨ Ýßí³Í

ï»ë³ÏÇ ë»÷³Ï³ÝáõÃÛáõÝ áõÝÇ: Ð³ñÏ³íáñ ¿ Ýß³Ý ¹Ý»É ëïáñ¨ Ýßí³Í 1, 2 ¨ 3 ïáÕ»ñÇó Ûáõñ³ù³ÝãÛáõñÇ ¹ÇÙ³ó:

´²ÄÆÜ 1

1. Î³ÝËÇÏ ·áõÙ³ñ Ï³Ù ãÏ³ÝËÇÏ³óí³Í í×³ñ³·ñ»ñ

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Ý»ñÏ³ Ñ³ßí»ÏßÇéÁ:

3. ¸áõù Ï³Ù Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³Ù Ù»ÏÇó ³í»ÉÇ ÷áË³¹ñ³ÙÇçáó áõÝÇ±

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Ï³Ù ·ñ³ÝóÙ³Ý ÷³ëï³ÃÕÃ»ñÇ, ³éùáõí³×³éùÇ å³ÛÙ³Ý³·ñ»ñÇ, í³×³éùÇ ëï³ó³Ï³ÝÝ»ñÇ

Ï³Ù ·Ý³Ñ³ïÙ³Ý ÷³ëï³ÃÕÃ»ñÇ å³ï×»ÝÝ»ñÁ:

5. ÊÝ¹ñáõÙ »Ýù Í³ÝáÃ³Ý³É ë»÷³Ï³ÝáõÃÛ³Ý ëïáñ¨ µ»ñí³Í óáõó³ÏÇÝ:

Üß³Ý ¹ñ»ù ³Ûë í³Ý¹³ÏáõÙ, »Ã» Ò»ñ ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³ÙÇ å³ïÏ³ÝáõÙ ¿ Ï³Ù »Ã» Ý³ Çñ ³Ýí³Ùµ

·ñ³Ýó³Í áõÝÇ Ñ»ï¨Û³É ³é³ñÏ³Ý»ñÇó Ù»ÏÁ Ï³Ù Ù»ÏÇó ³í»ÉÇÝ:

²Ýß³ñÅ ·áõÛù` µ³óÇ ³ÛÝ ïÝÇó, áñáõÙ ¸áõù µÝ³ÏíáõÙ »ù (³é³ÝÓÝ³ïÝ»ñ, µÝ³Ï³ñ³ÝÝ»ñ` µ³½Ù³µÝ³Ï³ñ³Ý

ß»ÝùáõÙ, ßÇÝáõÃÛáõÝÝ»ñ, ß³ñÅ³Ï³Ý ïÝ»ñ, óÏÛ³Ýë ·áõÛù (life estates), Ñ³Ù³ï»Õ û·ï³·áñÍíáÕ ³Ù³é³ÝáóÝ»ñ),

µ³ÅÝ»ïáÙë»ñ, ÷áË³¹³ñÓ ÑÇÙÝ³¹ñ³ÙÝ»ñ, §Individual Retirement Account¦-Ý»ñ (IRA-Ý»ñ), §Keogh¦-Ý»ñ Ï³Ù

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Ï³Ù ·áõÛù ¿ å³ÑíáõÙ` ï³ÝÁ µÝ³ÏíáÕ` ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³ÙÇ û·ïÇÝ), ¹³ï³í×éáí ß³Ñ³Í ·áõÙ³ñÝ»ñ,

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³é¨ïñ³ÛÇÝ ë»÷³Ï³ÝáõÃÛáõÝ, Ý³íÃÇ ¨ Ñ³Ý³ÍáÝ»ñÇ Çñ³íáõÝùÝ»ñ, $100.00-Çó ³í»ÉÇ ³ñÅáÕáõÃÛ³Ùµ

Ã³ÝÏ³ñÅ»ù Çñ»ñ (µ³Ûó á°ã ³ÙáõëÝ³Ï³Ý Ï³Ù Ýß³Ý³¹ñáõÃÛ³Ý Ù³ï³ÝÇÝ»ñ Ï³Ù ïáÑÙ³Ï³Ý Ã³ÝÏ³ñÅ»ù Çñ»ñ)

Ï³Ù $500 Ï³Ù ³í»ÉÇ ³ñÅáÕáõÃÛ³Ùµ ó³ÝÏ³ó³Í ³ÛÉ ³Ýß³ñÅ ·áõÛù, ³ÝÓÝ³Ï³Ý Çñ Ï³Ù ë»÷³Ï³ÝáõÃÛáõÝ:

ºÃ» ¸áõù Ýß³Ý ºø ¹ñ»É í³Ý¹³ÏáõÙ, ËÝ¹ñáõÙ »Ýù ³ÝóÝ»É 2-ñ¹ ´²ÄÜÆÜ (ëïáñ¨):

ºÃ» ¸áõù Ýß³Ý âºø ¹ñ»É ³Ûë í³Ý¹³ÏáõÙ, ËÝ¹ñáõÙ »Ýù ³ÝóÝ»É 3-ñ¹ ´²ÄÜÆÜ` 6-ñ¹ ¿çáõÙ:

´²ÄÆÜ 2

ºÃ» ¸áõù Ýß³Ý »ù ¹ñ»É í»ñÁ` 5-ñ¹ Ñ³Ù³ñÇ ï³Ï ·ïÝíáÕ í³Ý¹³ÏáõÙ, ËÝ¹ñáõÙ »Ýù Éñ³óÝ»É ³Ûë µ³ÅÇÝÁ ¨

å³ï³ëË³Ý»É ´àÈàð Ñ³ñó»ñÇÝ: ÊÝ¹ñáõÙ »Ýù ³Ûë Ã»ñÃÇÏÇ Ñ»ï ·ñ³íáñ ÷³ëï³ÃÕÃ»ñ ïñ³Ù³¹ñ»É ëïáñ¨ Ýßí³Í

µáÉáñ ³ÛÝ ËÙµ»ñÇ Ñ³Ù³ñ, áñáÝó ²Ûá »ù å³ï³ëË³Ý»É: ÜÙ³Ý ÷³ëï³ÃÕÃ»ñÇ ûñÇÝ³ÏÝ»ñ »Ý` ³å³Ñáí³·ñ»ñÁ,

å³ÛÙ³Ý³·ñ»ñÁ, ËÝ³Ù³·ñ»ñÁ, ³éùáõí³×³éùÇ å³ÛÙ³Ý³·ñ»ñÁ, ¹³ï³ñ³ÝÇ áñáßáõÙÝ»ñÁ, å³ñïùÇ Ù³ñÙ³Ý

ÃáõÛÉ³ïñ³·ñ»ñÁ, ß³ÑáõÛÃÇ ¨ íÝ³ëÇ ï»Õ»Ï³·ñ»ñÁ, ÇÝãå»ë Ý³¨ ë»÷³Ï³ÝáõÃÛ³Ý Çñ³íáõÝùÁ Ï³Ù ûñÇÝ³Ï³Ý

ß³ÑÁ óáõÛó ïíáÕ ³ÛÉ ÷³ëï³ÃÕÃ»ñ:

6. ´³ÅÝ»ïáÙë»ñ Ï³Ù ÷áË³¹³ñÓ ÑÇÙÝ³¹ñ³ÙÝ»ñ

ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É ù³Õí³ÍùÝ»ñÇ å³ï×»ÝÝ»ñÁ Ï³Ù ³ñÅ»ïáÙë»ñÇ Ï³Ù

÷áË³¹³ñÓ ÑÇÙÝ³¹ñ³ÙÇ Ñ³í³ëï³·ñ»ñÇ å³ï×»ÝÝ»ñÁ, áñáÝó íñ³ Ýßí³Í

¿ µ³ÅÝ»ïáÙë»ñÇ ÃÇíÁ:

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Page 3 of 7

MC 604 IPS ARM (5/14)

7. §Individual Retirement Account¦-Ý»ñ (IRA-Ý»ñ), §Keogh¦-Ý»ñ, ³ßË³ï³ÝùÇ Ñ»ï Ï³åí³Í

Ï»Ýë³Ãáß³Ï Ï³Ù Ï»Ýë³Ãáß³Ï³ÛÇÝ Ñ³ßÇíÝ»ñ, ûñÇÝ³Ï` 401k Ï³Ù 457 Ñ³ßÇíÝ»ñ

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ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É Ò»ñ ·áñÍ³ïáõÇ, ýÇÝ³Ýë³Ï³Ý Ñ³ëï³ïáõÃÛ³Ý Ï³Ù

í³×³é³ÙÇçÝáñ¹Ç ÏáÕÙÇó ïñí³Í ³Ù»Ý³í»ñçÇÝ ù³Õí³ÍùÝ»ñÁ, áñáÝó íñ³ Ýßí³Í

¿ ÑÇÙÝ³·áõÙ³ñÁ ¨ ß³ÑÁ, áñÁ ëï³ÝáõÙ »ù, Ï³Ù Ñ³ßíÇ Ï³ÝËÇÏ ·ÇÝÁ (·áõÙ³ñÁ

í³Õ³Å³Ù Ñ³Ý»Éáõ ¹»åùáõÙ Ý³Ë³ï»ëí³Í ïáõ·³ÝùÇó Ñ»ïá):

8. î³ñ»í×³ñÝ»ñ Ï³Ù ÏÛ³ÝùÇ ³å³Ñáí³·ñáõÃÛáõÝ

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9. ¶»ñ»½Ù³ÝÇ ï»Õ»ñ, ËÝ³Ù³éáõÃÛáõÝÝ»ñ, Ã³ÕÙ³Ý å³ÛÙ³Ý³·ñ»ñ,

Ã³ÕÙ³Ý ³å³Ñáí³·ñáõÃÛáõÝ

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10. ÊÝ³Ù³éáõÃÛáõÝÝ»ñ, ³ñ·»É³÷³Ïí³Í Ñ³ßÇíÝ»ñ (áñáÝó íñ³ ·áõÙ³ñ Ï³Ù ·áõÛù

¿ å³ÑíáõÙ` ï³ÝÁ µÝ³ÏíáÕ` ÁÝï³ÝÇùÇ áñ¨¿ ³Ý¹³ÙÇ û·ïÇÝ)

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11. ¸³ï³í×éáí ß³Ñ³Í ·áõÙ³ñÝ»ñ, å³ñïùÇ Ù³ñÙ³Ý å³ÛÙ³Ý³·ñ»ñ, ³åñáõëï³¹ñ³ÙÇ

Ù³ëÇÝ ¹³ï³ñ³ÝÇ áñáßáõÙÝ»ñ, ÙÇÝã³ÙáõëÝ³Ï³Ý ¨ Ñ»ï³ÙáõëÝ³Ï³Ý å³ÛÙ³Ý³·ñ»ñ

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12. ØáõñÑ³ÏÝ»ñ, ÑÇåáÃ»ÏÝ»ñ Ï³Ù ËÝ³Ù³·ñ»ñ

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ºÃ» ¸áõù ²Ûá »ù å³ï³ëË³Ý»É 6-Çó ÙÇÝã¨ 12-ñ¹ Ñ³ñó»ñÇó áñ¨¿ Ù»ÏÇÝ (í»ñÁ), ËÝ¹ñáõÙ »Ýù

ïñ³Ù³¹ñ»É Ù»½ ³å³Ñáí³·ñ»ñÇ, å³ÛÙ³Ý³·ñ»ñÇ, ËÝ³Ù³·ñ»ñÇ, ³éùáõí³×³éùÇ

å³ÛÙ³Ý³·ñ»ñÇ, ¹³ï³ñ³ÝÇ áñáßáõÙÝ»ñÇ, å³ñïùÇ Ù³ñÙ³Ý å³ÛÙ³Ý³·ñ»ñÇ Ï³Ù Ñ³ßíÇ

í»ñ³µ»ñÛ³É ÷³ëï³ÃÕÃ»ñÇ å³ï×»ÝÝ»ñÁ, áñáÝù óáõÛó »Ý ï³ÉÇë í×³ñáõÙÝ»ñÁ, Ý»ñÏ³

ßáõÏ³Û³Ï³Ý ³ñÅ»ùÝ»ñÁ, Ñ»ï·ÝÙ³Ý Ï³ÝËÇÏ ·áõÙ³ñÁ, Ñ³ßí»ÏßÇéÝ»ñÁ, Ý»ñ¹ñáõÙÝ»ñÁ

¨ µ³ßËáõÙÝ»ñÁ:

13. $100.00-Çó ³í»ÉÇ ³ñÅáÕáõÃÛ³Ùµ Ã³ÝÏ³ñÅ»ù Çñ»ñ (µ³Ûó á°ã ³ÙáõëÝ³Ï³Ý Ï³Ù

²Ûá

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ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É í³×³éùÇ ëï³ó³Ï³ÝÝ»ñÇ, ·Ý³Ñ³ïáõÙÝ»ñÇ,

³ñÅ»ùÇ Ñ³ßí³ñÏÇ Ï³Ù ³å³Ñáí³·ñÙ³Ý ÷³ëï³ÃÕÃ»ñÇ å³ï×»ÝÝ»ñÁ:

14. ²é¨ïñ³ÛÇÝ Ñ³ßÇíÝ»ñ ¨ ë»÷³Ï³ÝáõÃÛáõÝ

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ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É Ñ³ñÏ³·ñ»ñÁ, ³åñ³Ýù³·ñ»ñÁ, ëï³ó³Ï³ÝÝ»ñÁ,

ÃáõÛÉ³ïñ³·ñ»ñÁ, ß³ÑáõÛÃÇ ¨ íÝ³ëÇ ï»Õ»Ï³·ñ»ñÁ, Ï³Ù ë»÷³Ï³ÝáõÃÛ³Ý Çñ³íáõÝùÁ,

»Ï³ÙáõïÁ ¨/Ï³Ù Í³Ëë»ñÁ óáõÛó ïíáÕ ³ÛÉ ÷³ëï³ÃÕÃ»ñ:

15. Ü»ñÏ³ÛáõÙë ¸áõù` áñå»ë ë»÷³Ï³ÝáõÃÛáõÝ, áõÝ»±ù ³é³ÝÓÝ³ïáõÝ, µÝ³Ï³ñ³Ý`

µ³½Ù³µÝ³Ï³ñ³Ý Ï³Ù Ñ³Ù³ïÇñ³Ï³Ý ß»ÝùáõÙ, ³·³ñ³Ï, ÑáÕ³Ù³ë, ß³ñÅ³Ï³Ý ïáõÝ

Ï³Ù óÏÛ³Ýë ·áõÛù (life estate) (û·ï³·áñÍÙ³Ý Çñ³íáõÝù) ÙÇ ï³ÝÁ, áñÁ Ý»ñÏ³ÛáõÙë Ò»ñ

ïáõÝÝ ¿ Ï³Ù ³ÝóÛ³ÉáõÙ Ò»ñ ïáõÝÝ ¿ »Õ»É:

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ºÃ» ²Ûá, ¸áõù ³ÛÅÙ ³Û¹ ï³±ÝÝ »ù µÝ³ÏíáõÙ:

ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù ³Û¹ ï³Ý Ñ³ëó»Ý Ýß»É ³Ûëï»Õ ¨ ³ÝóÝ»É 16-ñ¹ Ñ³ñóÇÝ:

ºÃ» ¸áõù Ý»ñÏ³ÛáõÙë ³Û¹ ï³ÝÁ ã»ù µÝ³ÏíáõÙ, ³ÝóÛ³ÉáõÙ ³åñ»±É »ù ¹ñ³ÝáõÙ ¨ ÑáõÛë

áõÝ»±ù ³å³·³ÛáõÙ »ñµ¨¿ ÏµÝ³Ïí»ù ¹ñ³ÝáõÙ` áñå»ë Ò»ñ ï³ÝÁ:

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ºÃ» ²Ûá »ù å³ï³ëË³Ý»É, ³Ýó»ù 16-ñ¹ Ñ³ñóÇÝ:

Page 4 of 7

MC 604 IPS ARM (5/14)

ºÃ» àã »ù å³ï³ëË³Ý»É, Ò»ñ ÁÝï³ÝÇùÇ ëïáñ¨ Ýßí³Í ³Ý¹³ÙÝ»ñÇó áñ¨¿ Ù»ÏÁ Ï³Ù ÙÇ

ù³ÝÇëÁ Ý»ñÏ³ÛáõÙë ³åñáõ±Ù »Ý ³Û¹ ï³ÝÁ:

• Ò»ñ ÏÇÝÁ Ï³Ù ³ÙáõëÇÝÁ.

• ÙÇÝã¨ 21 ï³ñ»Ï³Ý »ñ»Ë³Ý.

• Ñ³ßÙ³Ý¹³Ù áñ¹ÇÝ Ï³Ù ¹áõëïñÁ.

• ËÝ³ÙÛ³É ³½·³Ï³ÝÁ, áñÁ ÝßíáõÙ ¿ Ñ³ñÏ³·ñÇ íñ³` áñå»ë ËÝ³ÙÛ³É.

• Ñ³ñ³½³ï ùáõÛñÁ Ï³Ù »Õµ³ÛñÁ, áñÁ ÝáõÛÝå»ë Ñ³Ý¹Çë³ÝáõÙ ¿ ï³Ý ë»÷³Ï³Ý³ï»ñ

¨ Ò»ñ Í»ñ³Ýáó ÷áË³¹ñí»Éáõó ³é³ç ³éÝí³½Ý Ù»Ï ï³ñÇ µÝ³Ïí»É ¿ ¹ñ³ÝáõÙ.

• Ò»ñ Í»ñ³Ýáó ÷áË³¹ñí»Éáõó ³ÝÙÇç³å»ë ³é³ç` ³éÝí³½Ý »ñÏáõ ï³ñÇ Ò»½ ËÝ³Ù»Éáõ

Ýå³ï³Ïáí` Ò»½ Ñ»ï ³Û¹ ï³ÝÁ µÝ³Ïí³Í` ÁÝï³ÝÇùÇ áñ¨¿ ³ÛÉ ³Ý¹³Ù, áñå»ë½Ç ¸áõù

Ç íÇ×³ÏÇ ÉÇÝ»ù ï³ÝÝ ³åñ»É:

²Ûá

àã

ºÃ» ²Ûá »ù å³ï³ëË³Ý»É, ³Ýó»ù 16-ñ¹ Ñ³ñóÇÝ:

ºÃ» àã »ù å³ï³ëË³Ý»É, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É ·áõÛù³Ñ³ñÏÇ ³Ù»Ý³í»ñçÇÝ Ñ³ßí³ñÏÇ

Ï³Ù ³Ýß³ñÅ ·áõÛùÇ Ñ³Ù³å³ï³ëË³Ý áñ³Ï³íáñáõÙ áõÝ»óáÕ ·Ý³Ñ³ïáÕÇ ÏáÕÙÇó

Ï³ï³ñí³Í ·Ý³Ñ³ïÙ³Ý ûñÇÝ³ÏÁ: Ø»Ýù Ïû·ï³·áñÍ»Ýù ·áõÛùÇ ³Ù»Ý³ó³Íñ ³ñÅ»ùÁ:

16. ²ÛÉ ³Ýß³ñÅ ·áõÛù, áñÁ å³ïÏ³ÝáõÙ ¿ Ò»½, µ³Ûó áñáõÙ ¸áõù ã»ù µÝ³ÏíáõÙ (ûñÇÝ³Ï`

µÝ³Ï³ñ³ÝÝ»ñ` µ³½Ù³µÝ³Ï³ñ³Ý ß»ÝùáõÙ, ßÇÝáõÃÛáõÝÝ»ñ, ß³ñÅ³Ï³Ý ïÝ»ñ, óÏÛ³Ýë

·áõÛù (life estates), Ñ³Ù³ï»Õ û·ï³·áñÍíáÕ ³Ù³é³ÝáóÝ»ñ)

²Ûá

àã

ºÃ» ²Ûá, ³å³ ³Û¹ ³Ýß³ñÅ ·áõÛù»ñÇó áñ¨¿ Ù»ÏÁ »Ï³Ùáõï µ»ñáõ±Ù ¿:

ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É ³Ù»Ý³í»ñçÇÝ í³ñÓ³í×³ñÇ ëï³ó³Ï³ÝÝ»ñÇ ¨ ÏáÙáõÝ³É

Í³é³ÛáõÃÛáõÝÝ»ñÇ, ·áõÛù³Ñ³ñÏÇ, ³å³Ñáí³·ñáõÃÛ³Ý, ëå³ë³ñÏÙ³Ý ¨ í»ñ³Ýáñá·Ù³Ý

Ñ³Ù³ñ Ý»ñÏ³Û³óí³Í Ñ³ßÇíÝ»ñÇ å³ï×»ÝÝ»ñÁ:

17. Ü³íÃÇ ¨ Ñ³Ý³ÍáÝ»ñÇ Çñ³íáõÝùÝ»ñ

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ºÃ» ¸áõù ²Ûá »ù å³ï³ëË³Ý»É 15-ñ¹, 16-ñ¹ Ï³Ù 17-ñ¹ Ñ³ñó»ñÇÝ, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É

ÑÇåáÃ»ÏÇ ÷³ëï³ÃÕÃ»ñÇ, ·áõÛù³Ñ³ñÏÇ ³Ù»Ý³í»ñçÇÝ Ñ³ßí³ñÏÇ, ·ñ³ÝóÙ³Ý ¨

ë»÷³Ï³ÝáõÃÛ³Ý ÷³ëï³ÃÕÃ»ñÇ å³ï×»ÝÝ»ñÁ:

18. $500 Ï³Ù ³í»ÉÇ ³ñÅáÕáõÃÛ³Ùµ ó³ÝÏ³ó³Í ³ÛÉ ³Ýß³ñÅ ·áõÛù, ³ÝÓÝ³Ï³Ý Çñ

Ï³Ù ë»÷³Ï³ÝáõÃÛáõÝ:

²Ûá

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ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù Ñ³Ûï³ñ³ñ³·ñ»ñ áõÕ³ñÏ»É ·áõÛùÇ ¨ ¹ñ³ ³ñÅ»ùÇ Ù³ëÇÝ:

19. ì»ñÁ` 2-Çó 18-ñ¹ Ñ³ñó»ñáõÙ Ýßí³Í ·áõÛùÇ Ï³Ù ³é³ñÏ³Ý»ñÇ Ù»ç Ï³±Ý ³ÛÝåÇëÇù, áñáÝó

û·ÝáõÃÛ³Ùµ ýÇÝ³Ýë³íáñí»É »Ý µÅßÏ³Ï³Ý Í³é³ÛáõÃÛáõÝÝ»ñÁ Ï³Ù »ñ³ßË³íáñí»É ¹ñ³Ýó

í×³ñáõÙÁ:

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ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù ³Ûë Ã»ñÃÇÏÇ í»ñçáõÙ ·ïÝíáÕ §Èñ³óáõóÇã ¹ÇïáÕáõÃÛáõÝÝ»ñÇ Ï³Ù

ï»Õ»ÏáõÃÛáõÝÝ»ñ¦ µ³ÅÝáõÙ, µ³ó³ïñ»É ¨ áñå»ë ³å³óáõÛó` Ïó»É ·ñ³í³¹ñÙ³Ý,

÷áË³éáõÃÛ³Ý Ï³Ù ³å³ÑáíÙ³Ý ÷³ëï³ÃÕÃ»ñÇ å³ï×»ÝÝ»ñÁ:

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20. ì»ñÁ` 2-Çó 18-ñ¹ Ñ³ñó»ñáõÙ Ãí³ñÏí³ÍÝ»ñÇ Ù»ç Ï³±Ý ³ÛÝåÇëÇù, áñáÝó Ñ³Ù³ñ

¸áõù ·áõÙ³ñ »ù å³ñïù:

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ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É ·ñ³í³¹ñÙ³Ý, ÷áË³éáõÃÛ³Ý Ï³Ù ³å³ÑáíÙ³Ý

÷³ëï³ÃÕÃ»ñÇ å³ï×»ÝÝ»ñÁ:

21. Ð³í³ëï³·ñí³Í §ºñÏ³ñ³ï¨ ËÝ³ÙùÇ Ñ³ñóáõÙ Î³ÉÇýáéÝÇ³ÛÇ Ñ³Ù³·áñÍ³ÏóáõÃÛáõÝ¦

(California Partnership for Long-Term Care) ³å³Ñáí³·Çñ

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àã

ºÃ» ²Ûá, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É Ò»ñ ³å³Ñáí³·ñÇ å³ï×»ÝÁ: ºÃ» ¸áõù í»ñÁ Ýßí³Í

³å³Ñáí³·ñáí Ýå³ëïÝ»ñ »ù ëï³ó»É, ËÝ¹ñáõÙ »Ýù áõÕ³ñÏ»É Ò»ñ ëï³ó³Í ³Ù»Ý³í»ñçÇÝ

§Üå³ëïÝ»ñÇ µ³ó³ïñáõÃÛ³Ý¦ å³ï×»ÝÁ:

Page 5 of 7

MC 604 IPS ARM (5/14)

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Form MC604 IPS ARM "Additional Income and Property Information Needed for Medi-Cal" - California (Armenian)

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