DOEA Form 154 Attachment 1 "Community Care for the Elderly (Cce) and Alzheimer's Disease Intitative (Adi) Eligibility Financial Worksheet and Assessed Co-payment Form" - Florida

What Is DOEA Form 154 Attachment 1?

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

Form Details:

  • The latest edition provided by the Florida Department of Elder Affairs;
  • 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 DOEA Form 154 Attachment 1 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA Form 154 Attachment 1 "Community Care for the Elderly (Cce) and Alzheimer's Disease Intitative (Adi) Eligibility Financial Worksheet and Assessed Co-payment Form" - Florida

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ATTACHMENT 1
2019
COMMUNITY CARE FOR THE ELDERLY (CCE) and ALZHEIMER’S DISEASE INTITATIVE (ADI)
ELIGIBILITY FINANCIAL WORKSHEET AND ASSESSED CO-PAYMENT FORM
EXEMPTIONS: Completion of this form is not required for Adult Protective Services (APS) high-risk
referrals and clients receiving Home Care for the Elderly.
1. CLIENT’S NAME ______________________
SPOUSE’S NAME ______________________
2. MONTHLY INCOME INFORMATION - Fill in all sources received.
Individual
Spouse
Total
a. Social Security (SSA), including Medicare premium
$
$
$
1 a). Supplemental Security Income (SSI)
$
$
$
2 a). Social Security Disability Insurance (SSDI)
$
$
$
b. Veterans Administration (VA) benefits
$
$
$
c. Disability Payments, including Worker’s Compensation
$
$
$
(Exclude disability payments reported under a. and b above)
d. Retirement Pension (Railroad, Union, Government and Private)
$
$
$
e. Interest/Dividend Income: Individual Retirement Accounts
(IRAs); Certificates of Deposits (CDs); bank accounts and
$
$
$
annuity income, including civil service
f. Rental Property Income
$
$
$
g. Estate/Trust Fund Income
$
$
$
h. Alimony
$
$
$
i. Regular Contributions from Another Person
$
$
$
j. Temporary Assistance for Needy Families (TANF)
$
$
$
k. Other Income
$
$
$
Total Gross Monthly Income
$
$
$
3. ASSESSED CO-PAYMENT MONTHLY AMOUNT (FROM CO-PAYMENT SCHEDULE)
$__________
DOEA Form 154 – 2019 Update
1
ATTACHMENT 1
2019
COMMUNITY CARE FOR THE ELDERLY (CCE) and ALZHEIMER’S DISEASE INTITATIVE (ADI)
ELIGIBILITY FINANCIAL WORKSHEET AND ASSESSED CO-PAYMENT FORM
EXEMPTIONS: Completion of this form is not required for Adult Protective Services (APS) high-risk
referrals and clients receiving Home Care for the Elderly.
1. CLIENT’S NAME ______________________
SPOUSE’S NAME ______________________
2. MONTHLY INCOME INFORMATION - Fill in all sources received.
Individual
Spouse
Total
a. Social Security (SSA), including Medicare premium
$
$
$
1 a). Supplemental Security Income (SSI)
$
$
$
2 a). Social Security Disability Insurance (SSDI)
$
$
$
b. Veterans Administration (VA) benefits
$
$
$
c. Disability Payments, including Worker’s Compensation
$
$
$
(Exclude disability payments reported under a. and b above)
d. Retirement Pension (Railroad, Union, Government and Private)
$
$
$
e. Interest/Dividend Income: Individual Retirement Accounts
(IRAs); Certificates of Deposits (CDs); bank accounts and
$
$
$
annuity income, including civil service
f. Rental Property Income
$
$
$
g. Estate/Trust Fund Income
$
$
$
h. Alimony
$
$
$
i. Regular Contributions from Another Person
$
$
$
j. Temporary Assistance for Needy Families (TANF)
$
$
$
k. Other Income
$
$
$
Total Gross Monthly Income
$
$
$
3. ASSESSED CO-PAYMENT MONTHLY AMOUNT (FROM CO-PAYMENT SCHEDULE)
$__________
DOEA Form 154 – 2019 Update
1
ATTACHMENT 1
4. ASSET INFORMATION – Fill in all sources.
Individual
Spouse
Total
a. More than one car (if car is less than 7 years old or
$
$
$
over 25 years old)
b. Cash Surrender Value of Life Insurance Policies
$
$
$
(only if total face value is over $2,500)
c. Checking Account(s)
$
$
$
d. Saving Account(s)
$
$
$
e. Cash on hand
$
$
$
f. Certificate(s) of Deposit (CDs)
$
$
$
g. Individual Retirement Account(s) (IRAs)
$
$
$
h. Revocable Burial Contract
$
$
$
i. Trust(s)
$
$
$
j. Stocks/Bonds/Mutual Funds
$
$
$
k. Real Property (not homestead)
$
$
$
Total Assets:
$
$
$
Deduct up to $2,500 in burial funds for an individual
$
$
$
(up to $5,000 in burial funds for a couple)
Subtotal Assets:
$
$
$
5. CLIENT’S STATEMENT AND SIGNATURE
By my signature below, I do hereby affirm that the income and asset information I have provided is a true and
correct statement of my present financial circumstances. I also authorize and agree to release to any
appropriate representative of the Community Care for the Elderly program or Alzheimer's Disease Initiative, as
applicable, any financial records needed to verify financial information. I agree to pay the co-pay amount
assessed for services delivered. I understand that the co-pay amount will not exceed the cost of the services I
receive each month. I have been informed of my right to request a review by the provider agency to resolve
any disagreements regarding the co-payments to be charged for services. If the resolution is still unsatisfactory
to me, I understand that I may appeal to the area agency on aging.
___________________________________________________________________________
Signature of Client or Responsible Party
Date
___________________________________________________________________________
Name of Worksheet Preparer
Date
DOEA Form 154 – 2019 Update
2
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