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State of Maryland Medical Assistance Manual Revised April 2014
MARYLAND MEDICAL ASSISTANCE PROGRAM INCOME AND SHELTER EXPENSE REPORTING FORM FOR COMMUNITY SPOUSE
CASE NAME: ____________________________
C.I.D. ___________________________________
My monthly income is ____________________________.
My monthly expenses for shelter are __________________________.
(Please indicate monthly amounts and attach form (s) of verification below.)
INCOME
Source of Income Monthly Amount
How Verified
Social Security
Veterans Benefits
_
Pension
_
Earned Income
_
Other
_
___________________________________
Total
$___________________________
___________________________________
SHELTER EXPENSES
Source of Expenses
Monthly Amount
How Verified Rent
$
Mortgage Payment
Condo Fees
Property Taxes
Homeowner’s Insurance
Heat (if not included in rent)
Water
Gas and Electric
Total $
I, the undersigned, declare the information provided above to be accurate and true.
Signature of Spouse
Date
DES 2003 (LTC) Revised 11/03