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State of Maryland Medical Assistance Manual Revised April 2014

Case Name _____________________________ CID Number ___________________________

II. Current Resource Month of Application _________________

Owner * Type Verification Full Value Unavailable /Excluded Value Countable Value

$ $ $

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

*Legend J = Joint SP = Spouse AP = Applicant

DHMH 4354 (Revised 3/07) (2 of 3)