Free Caretaker Supplement Application - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22571 (Rev. 07/2008)

STATE OF WISCONSIN

CARETAKER SUPPLEMENT APPLICATION
NOTE: Before completing this form, read the instructions (F-22571A). Print using black or blue ink. Use an additional sheet of paper if more space is needed. SECTION I - CLIENT INFORMATION
Name of Person Applying for Caretaker Supplement (Last, First, MI) Telephone Number (Include area code)

Address of Person Applying for Caretaker Supplement (Street, City, State, Zip Code)

Mailing Address (Only if different from residence)

SECTION II - GENERAL INFORMATION Refer to instructions to complete this section.
Name of all Family Members Living in Your Household Name (Last, First, MI) Social Security * Number (SSN) (Applicants Only) Date of Birth (mm/dd/yyyy) Gender M F M F M F M F M F M F M F M F M F M F Marital Status Code US Citizen (Applicants Only) Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Race or Ethnic Code (Optional) Relationship to Applicant

* Providing or applying for a Social Security Number (SSN) is voluntary; however, any person who wants to receive Caretaker Supplement (CTS), but does not want to
provide his or her SSN or apply for one, will not be eligible for benefits, pursuant to Wis. Stats. sec. 49.82(2).

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22571 (Rev. 07/2008)

STATE OF WISCONSIN

2

SECTION III - ABSENT PARENT INFORMATION Yes No Do any children have a natural or adoptive mother or father who is not living at home? If "Yes" complete below. If "No" go to Section IV.
Name of Parent (Last, First, MI) Social Security Number Date of Birth (mm/dd/yyyy) Name(s) of Child(ren) Relationship to Child Mother Father Mother Father Reason for Parent's Absence Date Parent Left Household Date Last Contact With Parent Court Order of Divorce / Paternity Case Number County State

SECTION IV - EMPLOYMENT Yes No Are you or any household members working? If you answered "Yes", complete below. If "No", go to Section V.
1. Name of Working Person Name of Employer

Yes

No Is anyone listed below a migrant worker?

Address of Employer (Street, City, State, Zip Code)

Employer's Telephone Number

Date Employment Began (mm/dd/yyyy)

Gross Monthly Earnings Expected This Month (Before taxes and deductions) Name of Employer

Gross Monthly Earnings Expected Next Month (Before taxes and deductions)

2.

Name of Working Person

Address of Employer (Street, City, State, Zip Code)

Employer's Telephone Number

Date Employment Began (mm/dd/yyyy)

Gross Monthly Earnings Expected This Month (Before taxes and deductions)

Gross Monthly Earnings Expected Next Month (Before taxes and deductions)

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22571 (Rev. 07/2008)

STATE OF WISCONSIN

3

SECTION V - SELF-EMPLOYMENT Yes No Are you or any household members self-employed? If you answered "Yes", complete below. If "No", go to Section VI.
1. Name (Last, First, MI) Name of Business

Address of Business (Street, City, State, Zip Code)

Type of Business

Net Annual Income

Depreciation Amount Claimed

Income You Expect to Earn This Year

$
2. Name (Last, First, MI)

$
Name of Business

$

Address of Business (Street, City, State, Zip Code)

Type of Business

Net Annual Income

Depreciation Amount Claimed

Income You Expect to Earn This Year

$

$

$

SECTION VI - UNEARNED INCOME Refer to instructions to complete this section. Yes No Does anyone in your household receive unearned income? If you answered "Yes", complete section below for each income type. If "No", go to Section VII.
Type of Income Social Security / Supplemental Security Income (SSI) Maintenance / Child Support Workers Compensation Unemployment Insurance Disability / Sick Pay Interest / Dividends Veterans Benefits *Other Income - List type(s) below: Yes Yes Yes Yes / No Yes Yes Yes Yes Yes Yes Yes Name of Person Receiving Unearned Income Gross Monthly Amount

No No No No No No No

$ $ $ $ $ $ $ $ $ $

No No No

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22571 (Rev. 07/2008)

STATE OF WISCONSIN

4

SECTION VII - ASSETS List all assets owned by the applicant(s). Include assets owned jointly. Do not include the value of personal household belongings, unless of unusual value. Do not include assets of any household member that is receiving SSI. List vehicles in Section VIII.
Type of Asset 1. Cash Cash 2. Checking Account Checking Account 3. Savings Account Savings Account 4. Real Estate / Property Real Estate / Property 5. Burial Assets / Burial Insurance Burial Assets / Burial Insurance 6. Life Insurance Life Insurance *Other Asset Type - List 7. Name of Owner(s) Current Value Description (e.g., Bank / Financial Institution Name, Account Number)

$ $ $ $ $ $ $ $ $ $ $ $

$ $

*OTHER ASSET TYPES: Certificate of Deposit, trust funds or life estates, stocks, bonds, IRA, Keogh Plan or other tax shelter, farm equipment, livestock, personal property of exceptional value (art collections, coin collections, jewelry, etc.), land contracts and mortgages, etc.

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22571 (Rev. 07/2008)

STATE OF WISCONSIN

5

SECTION VIII - VEHICLE INFORMATION List all vehicles owned by applicant(s). Include vehicles owned jointly with another person.
1. Vehicle Type Vehicle Year, Make and Model Name of the Owner(s)

Amount Still Owed on This Vehicle

Vehicle is Used to Get to Medical Appointments Yes No Name of the Owner(s)

Vehicle is Used for Employment, Training, School or Farming Yes No

$
2. Vehicle Type

Vehicle Year, Make and Model

Amount Still Owed on This Vehicle

Vehicle is Used to Get to Medical Appointments Yes No

Vehicle is Used for Employment, Training, School or Farming Yes No

$
SECTION IX - CHILD SUPPORT
Child Support is Being Paid Yes No

Name of Person Paying Child Support

Name of Person Who Receives the Child Support Payments

Monthly Amount

$
Names of Any Pregnant Women

SECTION X - PREGNANCY
Are any Members of Your Household Pregnant? Yes No Yes No Are multiple births expected? If "Yes" number of babies expected:

Due Date(s) (mm/dd/yyyy)

SECTION XI - RIGHTS AND RESPONSIBILITIES Read the Rights and Responsibilities section in the Instructions before signing this form. I understand the questions and statements on this application form. I understand the penalties for giving false information or breaking the rules. I certify, under penalty of false swearing, that all my answers are correct and complete to the best of my knowledge, including information provided about the citizenship status of each household member applying for benefits. I understand and agree to provide documents to prove what I have said. I understand that the agency may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits.

SIGNATURE - Applicant or Authorized Representative

Date Signed