Form W-1 LTC "Long-Term Care/Waiver Application" - Connecticut

What Is Form W-1 LTC?

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

Form Details:

  • Released on July 1, 2013;
  • The latest edition provided by the Connecticut State Department of Social 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 W-1 LTC by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Social Services.

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Download Form W-1 LTC "Long-Term Care/Waiver Application" - Connecticut

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State of Connecticut
Client ID:
Department of Social Services
W-1 LTC (New 07-2013)
Long-term Care/Waiver Application
Page 1 of 21
Items Needed for Your Long-Term Medical Care / Home Care Application
KEEP PAGES 1 and 2 FOR YOUR RECORDS
If you do not already get Long-Term Care Medical Assistance or Home Care Assistance from the Department of
Social Services, we need the items listed below to process your application. Send copies, do not send originals.
In some cases, we may request more documents than those listed below. If we do, we will give you time to send us
them. If you do not have, or if you need help getting the needed documents, contact DSS for help.
DO NOT WAIT TO APPLY
If you do not have copies of all the documents listed, send us what you have when you apply. It is important that you
apply as soon as possible. We will give you more time to send the other documents we need.
Each month you will need to pay a portion of your income to the nursing home; this is called applied income. A
married applicant may be able to give a part of their income to their spouse in the community. The following is needed
to make this determination:
Spouse’s monthly gross income
Property tax bill
Condo fees
Rent/Lease
Mortgage payment
Electric bill
Lot rental amount
Homeowner’s insurance
The following documents are needed from you and your spouse to determine if you are eligible for Long-Term Care
Medical Assistance or Home Care Assistance from DSS:
Federal law requires DSS to review 5 years of bank and financial statements on all accounts owned and co-
owned by you and your spouse. DSS does this by reviewing 2 full years of statements from the date of
application including the current month and statements for December of the remaining 3 years showing the
year to date interest. If you cannot provide the statements for the 3 remaining years you can provide your
federal tax returns. You must also explain any deposits or withdrawals of $5,000.00 or more.
Stocks
Bonds
Money Market Funds
Certificates of Deposit
Mutual Funds, Treasury and other notes
Retirement Accounts
IRA and Keogh Accounts
Annuities (a copy of the original annuity contract in addition to the statements)
Trusts
Current gross monthly income from all sources including:
Social Security
Railroad Retirement
VA Pensions
Private pensions
Annuities (a copy of the original annuity contract in addition to the statements)
State of Connecticut
Client ID:
Department of Social Services
W-1 LTC (New 07-2013)
Long-term Care/Waiver Application
Page 1 of 21
Items Needed for Your Long-Term Medical Care / Home Care Application
KEEP PAGES 1 and 2 FOR YOUR RECORDS
If you do not already get Long-Term Care Medical Assistance or Home Care Assistance from the Department of
Social Services, we need the items listed below to process your application. Send copies, do not send originals.
In some cases, we may request more documents than those listed below. If we do, we will give you time to send us
them. If you do not have, or if you need help getting the needed documents, contact DSS for help.
DO NOT WAIT TO APPLY
If you do not have copies of all the documents listed, send us what you have when you apply. It is important that you
apply as soon as possible. We will give you more time to send the other documents we need.
Each month you will need to pay a portion of your income to the nursing home; this is called applied income. A
married applicant may be able to give a part of their income to their spouse in the community. The following is needed
to make this determination:
Spouse’s monthly gross income
Property tax bill
Condo fees
Rent/Lease
Mortgage payment
Electric bill
Lot rental amount
Homeowner’s insurance
The following documents are needed from you and your spouse to determine if you are eligible for Long-Term Care
Medical Assistance or Home Care Assistance from DSS:
Federal law requires DSS to review 5 years of bank and financial statements on all accounts owned and co-
owned by you and your spouse. DSS does this by reviewing 2 full years of statements from the date of
application including the current month and statements for December of the remaining 3 years showing the
year to date interest. If you cannot provide the statements for the 3 remaining years you can provide your
federal tax returns. You must also explain any deposits or withdrawals of $5,000.00 or more.
Stocks
Bonds
Money Market Funds
Certificates of Deposit
Mutual Funds, Treasury and other notes
Retirement Accounts
IRA and Keogh Accounts
Annuities (a copy of the original annuity contract in addition to the statements)
Trusts
Current gross monthly income from all sources including:
Social Security
Railroad Retirement
VA Pensions
Private pensions
Annuities (a copy of the original annuity contract in addition to the statements)
State of Connecticut
Client ID:
Department of Social Services
W-1 LTC (New 07-2013)
Long-term Care/Waiver Application
Page 2 of 21
Face and cash value of Life Insurance Policies (current annual statement)
Burial Contracts (Irrevocable and Revocable)
Burial Plot Deeds
Life Use documents
Privately held Promissory Notes
Reverse Mortgage Documents - monthly/quarterly statements are required for the 60 month look back
Real Estate Purchase/Warranty Deeds
Quit Claim Documents
Trusts and Annuities (including appendices, schedules, annual accountings, and amendments for the past 5
years)
Private Health Insurance Cards including Medicare (copy of both sides)
Health Insurance Premium Amounts
A copy of your spouse’s death certificate, Will and Probate Inventory Document if your spouse died in the
past 5 years.
A copy of your divorce decree if you were divorced in the past 5 years.
Power of Attorney or Conservator Documents (if any)
The asset limit for Long-Term Care and Home Care Medicaid is $1600.00. You will not qualify for assistance
in any month in which your assets exceed $1600.00.
If you are in a nursing facility you should be paying the nursing facility during the application process.
Contact the business office of your facility to find out what is due to the facility during this time frame.
Continue by completely answering every question on the attached application.
Attach additional sheets if you need more space to complete the application. Please be sure to include your
name, DSS client ID number or your social security number on each additional sheet.
State of Connecticut
Client ID:
Department of Social Services
W-1 LTC (New 07-2013)
Long-term Care/Waiver Application
Page 3 of 21
FOR WORKER
Worker’s Name: __________________________ Application Date: __________
USE ONLY
Office: _______________
This part is for
our staff.
Programs Applied for or receiving: _________________________
Continue to
Section A
.
Assistance Unit IDs and Client IDs: _________________________
SECTION A – APPLICANT INFORMATION: Tell us about yourself.
I am applying for:
Care in a facility
Home Care
Last Name
First Name
Middle Initial
Suffix
_______________________
_________________________
________
______ (Jr., Sr., etc.)
Maiden Name or Other Name
________________________
Social Security Number:
Date of Birth: ______/_____/______
If you have a Social Security Number, enter it
Place of Birth: ___________________________
here.
_______ - _______ - _________
Gender:
Male
Female
Marital Status:
Never Married
Married
Divorced
Separated
(Check one)
Widowed, date of death for your spouse: ____________
If married please provide your spouse’s name:
Last Name
First Name
Middle Name
Suffix
Maiden Name or Other Name
____________________ _______________
_____________
_____
_______________________
(Jr., Sr., etc.)
Are you a resident of Connecticut?
Yes
No
Are you a U.S. Citizen?
Yes
No If No, complete SECTION E – IMMIGRATION STATUS, below.
What is your primary language? _______________________________
Do you need an interpreter?
Yes
No
Do you have a disability?
Yes
No
If Yes, do you need an accommodation or special help applying because of your disability?
Yes
No
What type of accommodation or special help do you need?
_________________________________________________________________________________________
Ethnicity:
Are you Hispanic or Latino?
Race:
Native American
Asian
Optional
Yes
No
Alaskan Native/Eskimo
Black/African descent
White
You are not required to provide race or ethnic origin; however, your cooperation will help determine
compliance with the federal civil rights law. If you do not wish to give this information, it will in no way
affect consideration of your application. We are authorized to ask this information under Title VI of the
Civil Rights Act of 1964.
State of Connecticut
Client ID:
Department of Social Services
W-1 LTC (New 07-2013)
Long-term Care/Waiver Application
Page 4 of 21
SECTION B – CURRENT ADDRESS of Your HOME or INSTITUTION/LONG-TERM CARE FACILITY:
Tell us about your home or Long-term Care Facility, if you live in one.
What is the address of your home?
Street ____________________________________________________________
City _____________________ State _________ Zip ___________
Telephone # ________________ Cell # _______________________
Are you a U.S. Citizen? □ Yes □ No
If you answered NO, complete SECTION E- IMMIGRATION STATUS, below.
Is this your mailing address?
Yes
No If No, provide your mailing address.
__________________________________________________________________________________________
Do you or your spouse own your home?
Yes
No
If No, do you have life use of the property?
Yes
No
If you live in a facility, what is the name of the facility? _____________________________________
What is the address of the facility?
Street ____________________________________________________________
City _____________________ State _________ Zip ___________
On what date did you enter the facility? ____/ ____/ ____
SECTION C – PREVIOUS ADDRESSES: If you have lived at your current address for less than five years, tell us
where you lived before.
Street _____________________________________________________________
City __________________________
State _________
Zip _____________
Did you or your spouse own this home?
Yes
No
Street ______________________________________________________________
City __________________________
State __________
Zip _____________
Did you or your spouse own this home?
Yes
No
SECTION D – AUTHORIZED REPRESENTATIVE(S): Do you authorize someone to represent you in this
application? Yes No Are you making this application as a representative for someone else? Yes No
If you answered Yes to either question, complete the section below. This individual(s) will receive correspondence
from the department regarding your application and they will be able to contact the department regarding your
application.
First Name
Last Name
Suffix
_________________
________________
____________
(Jr., Sr., etc.)
Address _________________________________________________________________________________
City______________________________________ State ____________ Zip __________________________
State of Connecticut
Client ID:
Department of Social Services
W-1 LTC (New 07-2013)
Long-term Care/Waiver Application
Page 5 of 21
SECTION D – AUTHORIZED REPRESENTATIVE(S): (continued)
Home Telephone # _________________
Type of Representative: Send Proof
Cell # _______________
Conservator
Work Telephone # _________________
Power of Attorney
Email: __________________________
Guardian
First Name
Last Name
Suffix
_________________
________________
____________
(Jr., Sr., etc.)
Address ___________________________________________________________________________________
City________________________________________ State ____________ Zip __________________________
Type of Representative: Send Proof
Home Telephone # _________________
Cell # _______________
Conservator
Work Telephone # _________________
Power of Attorney
Email: __________________________
Guardian
SECTION E – IMMIGRATION STATUS (FOR NON-CITIZENS ONLY)
SEND PROOF Send a copy of the front and back of your immigration card or other immigration document.
What is your current USCIS status? ______________________
On what date did you receive your status? _____/ _____/ _____
Do you have a sponsor?
Yes
No
Sponsor’s name and address: __________________________________________________________________
What is your Country of Origin? ________________________
When did you enter the United States? ____/ ____/ ____
What is your USCIS number? ____________________________
If you are a refugee, list your Refugee Resettlement Agency:
_________________________________________________________________________________________
SECTION F – MILITARY SERVICE / VETERAN INFORMATION:
Have you or your spouse ever served in the U.S. Military?
Yes
No
Have you been rated with a service related disability?
Yes
No
Veteran’s Name
Relationship to Veteran
Veteran’s Status
Military Service #
___________________
___________________
____________________
______________________