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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM DECLARATION OF JOINT BANK ACCOUNT OWNERSHIP INTEREST

(e.g., Savings and Checking Accounts, Money Market Accounts, Certificates of Deposit) I. Type of Account _________________________ Account No. _______________________ Name of Bank or Financial Institution _______________________________________________ Address ______________________________________________________________________ ______________________________________________________________________

Name of Owners

S.S. # Relationship to A/R Ownership Interest 1. _______________________________________________________________________________ 2. ________________________________________________________________________________ 3. ________________________________________________________________________________

Total Amount in Account ________________________________________________________

II. Type of Account ________________________ Account No. ________________________ Name of Bank or Financial Institution _______________________________________________ Address ______________________________________________________________________ _______________________________________________________________________ Name of Owners

S.S. # Relationship to A/R Ownership Interest 1. _______________________________________________________________________________ 2. ________________________________________________________________________________ 3. ________________________________________________________________________________

Total Amount in Account ________________________________________________________ We, the undersigned, declare the statements made above to be accurate and true. We, also understand that this declaration may be subsequently changed or rescinded only if such action results in an increase in funds for _________________________________________________________ Name of Applicant/Recipient If there are additional accounts, use an additional form.

________________________________________________ ______________________

Signature of Applicant/Recipient (or Representative)

Date

________________________________________________ ______________________

Signature of Co-Owner

Date

________________________________________________ ______________________ Signature of Co-Owner Date

DHMH 4343 Revised 12/08