Form DHS-4574-B "Assets Declaration Patient and Spouse" - Michigan

What Is Form DHS-4574-B?

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

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS-4574-B by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DHS-4574-B "Assets Declaration Patient and Spouse" - Michigan

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ASSETS DECLARATION
FOR OFFICE USE ONLY
PATIENT AND SPOUSE
Beneficiary Name
Michigan Department of Health and Human Services
(Skip if no spouse)
Client ID
Case Number
County
District
Section
Unit
Specialist
PLEASE PRINT
Patient’s Name (First, Middle, Last)
Phone No. of Nursing Home Spouse’s Name (First, Middle, Last)
Spouse’s Phone No.
Address of Nursing Home (Number, Street, Rural Route)
Spouse’s Address (Number, Street, Rural Route)
City
State
Zip Code
City
State
Zip Code
Patient’s Birthdate (Mo/Day/Yr)
Patient’s Social Security
Spouse’s Birthdate (Mo/Day/Yr
Spouse’s Social Security*
This form asks questions about the property or assets owned by you and/or your spouse. This information is needed to determine
your eligibility for Healthcare Coverage and the amount of assets that can be protected for the benefit of your spouse. Answer the
following questions by providing information about all assets owned by you and/or your spouse as of _________________________.
Include assets you or your spouse own jointly with family or other persons.
ASSETS
1. Do you and/or your spouse have any assets (include assets held jointly)?
c
4
c
Yes
Check all types of assets your household has and complete the table
No
c
c
c
Checking/draft account
Money market accounts
Savings/share accounts
c
c
c
Certificates of Deposit (CD)
Christmas club accounts
Patient trust fund
c
c
c
Case on hand or in safe deposit
Savings, bonds, stocks or mutual funds
IRA, KEOGH, 401K or Deferred
Compensation account(s)
c
c
c
Trust or Annuity
Land contract, mortgage or other
Real estate (including place you live)
notes payable to household member
c
c
c
Life estate/life lease
Burial plot(s), casket, etc.
Tools, equipment, livestock or crops
c
c
c
Life insurance
Other Assets ___________________
Health Savings Account
c
Burial trust/funeral contract(s)
Owner(s)
Type(s)
Balance
Name and address
Account/policy
of asset(s)
of Asset(s)
amount of value
(bank, insurance company, etc.)
number, etc.
The Michigan Department of Health and Human Services (MDHHS) does not
discriminate against any individual or group because of race, religion, age,
AUTHORITY:
42 CFR Part 435.
COMPLETION:
Voluntary.
national origin, color, height, weight, marital status, genetic information, sex,
PENALTY:
No Healthcare Coverage.
sexual orientation, gender identity or expression, political beliefs or disability.
*Optional if the community spouse is not requesting assistance.
1
DHS-4574-B (Rev. 5-16) Previous edition obsolete.
ASSETS DECLARATION
FOR OFFICE USE ONLY
PATIENT AND SPOUSE
Beneficiary Name
Michigan Department of Health and Human Services
(Skip if no spouse)
Client ID
Case Number
County
District
Section
Unit
Specialist
PLEASE PRINT
Patient’s Name (First, Middle, Last)
Phone No. of Nursing Home Spouse’s Name (First, Middle, Last)
Spouse’s Phone No.
Address of Nursing Home (Number, Street, Rural Route)
Spouse’s Address (Number, Street, Rural Route)
City
State
Zip Code
City
State
Zip Code
Patient’s Birthdate (Mo/Day/Yr)
Patient’s Social Security
Spouse’s Birthdate (Mo/Day/Yr
Spouse’s Social Security*
This form asks questions about the property or assets owned by you and/or your spouse. This information is needed to determine
your eligibility for Healthcare Coverage and the amount of assets that can be protected for the benefit of your spouse. Answer the
following questions by providing information about all assets owned by you and/or your spouse as of _________________________.
Include assets you or your spouse own jointly with family or other persons.
ASSETS
1. Do you and/or your spouse have any assets (include assets held jointly)?
c
4
c
Yes
Check all types of assets your household has and complete the table
No
c
c
c
Checking/draft account
Money market accounts
Savings/share accounts
c
c
c
Certificates of Deposit (CD)
Christmas club accounts
Patient trust fund
c
c
c
Case on hand or in safe deposit
Savings, bonds, stocks or mutual funds
IRA, KEOGH, 401K or Deferred
Compensation account(s)
c
c
c
Trust or Annuity
Land contract, mortgage or other
Real estate (including place you live)
notes payable to household member
c
c
c
Life estate/life lease
Burial plot(s), casket, etc.
Tools, equipment, livestock or crops
c
c
c
Life insurance
Other Assets ___________________
Health Savings Account
c
Burial trust/funeral contract(s)
Owner(s)
Type(s)
Balance
Name and address
Account/policy
of asset(s)
of Asset(s)
amount of value
(bank, insurance company, etc.)
number, etc.
The Michigan Department of Health and Human Services (MDHHS) does not
discriminate against any individual or group because of race, religion, age,
AUTHORITY:
42 CFR Part 435.
COMPLETION:
Voluntary.
national origin, color, height, weight, marital status, genetic information, sex,
PENALTY:
No Healthcare Coverage.
sexual orientation, gender identity or expression, political beliefs or disability.
*Optional if the community spouse is not requesting assistance.
1
DHS-4574-B (Rev. 5-16) Previous edition obsolete.
ASSETS
2. Does anyone in your household have any vehicles?
c
4
c
Yes
Check all types of assets your household has and complete the table
No
c
c
c
c
c
c
c
Car
Truck
Boat
Camper/trailer
Motorcycle
RV
Other Vehicle
Owner(s)
(As shown on vehicle title
or registration)
Year
Make/Model
Amount Owed
3. Has anyone in your household:
sold or given away property, land, vehicles, stocks, bonds, savings, cash,
c
4
Yes
Who:
checking, income, etc., closed any accounts or removed or added a name
c
No
on any asset within the last 60 months?
filed a pending lawsuit which may bring money, property, etc.?
c
4
Yes
Who:
c
No
received a one-time cash payment (such as worker’s compensation,
c
4
Yes
Who:
lottery winnings, insurance settlement, lawsuit award, etc.) within the last
c
No
60 months?
or has anyone acting for any household member, ever put any money,
c
4
Yes
Who:
lawsuit settlement, income or assets in a trust, annuity or similar legal
c
No
device?
AFFIDAVIT
I swear or affirm that all the information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted
for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I
also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance
I am not entitled to or more assistance than I am entitled to, I can be prosecuted for fraud.
Estate Recovery. I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal
right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some or all of my estate may be
recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is
under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due
to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not.
Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective
date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be
submitted to determine if the applicant qualifies for an undue hardship waiver. Undue hardship waivers are temporary. For further
information regarding Estate Recovery, call 800-642-3195.
Signature (Patient or Representative)
Date (Month, Day, Year)
Two Witnesses Only
Signature of First Witness
Signature of Second Witness
If Signed by Mark X
NOTE:
If you signed this application on behalf of someone else, complete the information below.
Name (First, Middle, Last)
Phone Number
Relationship to Patient
Street Address
City
State
Zip Code
2
DHS-4574-B (Rev. 5-16) Previous edition obsolete.
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