Form 218 "Lien Information Sheet - Sample" - Alabama

What Is Form 218?

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

Form Details:

  • Released on January 20, 1995;
  • The latest edition provided by the Alabama Medicaid Agency;
  • 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 218 by clicking the link below or browse more documents and templates provided by the Alabama Medicaid Agency.

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Download Form 218 "Lien Information Sheet - Sample" - Alabama

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Lien Information Sheet
Claimant’s Name: _____________________________
________________________
1.
Street address of lien property ________________________________________________
2.
Spouse ____________________________________
Living? ________________________
Address _____________________________________
Lien Property? _______________
3.
Does claimant have a child who is blind, disabled or under 21?
Yes
No
If yes, specify which _______________
Name ___________________________________
Address ___________________________________
___________________________________
4.
Names, addresses of children not named in (3). Specify (D) if deceased.
Name
Street Address
City, State, Zip
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
5.
List children of claimant’s deceased children with complete address. Specify
parent.
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
6.
List names of brothers/sisters of claimant. Specify (D) if deceased. Give
complete address.
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
- over -
Form 218 (Revised 1/20/95)
Alabama Medicaid Agency
Lien Information Sheet
Claimant’s Name: _____________________________
________________________
1.
Street address of lien property ________________________________________________
2.
Spouse ____________________________________
Living? ________________________
Address _____________________________________
Lien Property? _______________
3.
Does claimant have a child who is blind, disabled or under 21?
Yes
No
If yes, specify which _______________
Name ___________________________________
Address ___________________________________
___________________________________
4.
Names, addresses of children not named in (3). Specify (D) if deceased.
Name
Street Address
City, State, Zip
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
5.
List children of claimant’s deceased children with complete address. Specify
parent.
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
6.
List names of brothers/sisters of claimant. Specify (D) if deceased. Give
complete address.
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
- over -
Form 218 (Revised 1/20/95)
Alabama Medicaid Agency
7.
Give names and complete addresses of children of claimant’s deceased
brothers/sisters. Specify parent.
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
8.
List names, addresses of co-owners of property.
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
9. Ownership interest of claimant. _______________________________________________
10. List other liens, judgments, mortgages, encumbrances, against property. Give
holder, date taken, and balance owed.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
11. Does claimant have a will?
Yes
No
(If yes, answer 12 – 13)
12. Give names and addresses of heirs to property named in will.
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
_________________________
_________________________
_______________________
13. Give name and address of executor/administrator named in will.
_______________________________________________________________________________
_____________________________________
Address _________________________________
Signature of Person Completing Form
_________________________________
Date ________________________________
Phone _________________________________
Form 218 (Revised 1/20/95)
Alabama Medicaid Agency
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