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State of Maryland Medical Assistance Manual Revised April 2014

Maryland Medical Assistance Program TRANSFER/DISPOSAL OF ASSETS WORKSHEET

(Complete a worksheet for each transfer)

Client’s Name: ____________________ Client ID: __________________________ Local Department of Social Services/DEWS: __________________________________

Application Date: ___________________ Date of Transfer: ____________________

Date of Eligibility: ____________________

Check all that apply:

1. Was the Resource transferred to, or for the sole benefit, of any of the individuals identified below?

____ Spouse, ____ Blind or Disabled Son or Daughter, ____ Unmarried Child under 21 Years of Age

2. Was a Trust Fund established for the Sole Benefit of a Disabled Person Under 65 Years of Age ? _____

3. Was Home Property Transferred to the Person’s: ____ Spouse,

____ Sibling with an equity interest, currently residing in the home, and resided at least 1 year prior to institutionalization; ____ Unmarried Child under 21 Years of Age; ____ Blind or Disabled Son or Daughter; or ____ Son or Daughter currently residing in the home, resided at least 2 years prior to institutionalization and verified parental care was provided to enable the institutionalized parent to reside at home rather than in an institution?

If the transfer was made to any of the above identified individuals, STOP HERE! If not, proceed to the next section.

DES/LTC 811 Revised 12/08

(1)