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State of Maryland Medical Assistance Manual Revised April 2014

Resources Evaluation

For Married Applicants Institutionalized on or after 9/30/89

Case Name ____________________________________

CID Number ___________________________________

I. Assessment Month of Institutionalization ____________

Owner* Type Verification Full Value Unavailable Excluded Value Countable Value

$ $ $

A. Total Assessed Resources (as of Month of Institutionalization) $

B. ½ of line A $

C. Enter the lesser of line B or maximum spousal share (MA-8) $

*Legend J=Joint SP=Spouse AP=Applicant

DHMH 4354 (Revised 3/07) (1 of 3)