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State of Maryland Medical Assistance Manual Revised April 2014

III. Attribution of Resources

A. Total from Section II.

$__________________

B. Enter the following amounts:

Amount from Section I Line C

$__________________

Minimal Spousal Share (MA –8)

$ __________________

Amount per Hearing or Court Order

$ __________________

C. Enter greatest amount from Section III Line B

- __________________

D. Resources Attributed to Applicant

$__________________

Schedule MA-2

$__________________

Excess Resources

$__________________ □Resources Exceed Standard: Ineligible

□Resources Within Standard: Proceed to Section IV

IV. 90 Day Post-Eligibility Transfer Period Value of resources owned by applicant in the month of application (List Resources from Section II) Onwer* Type Verification Full Value Unavailable Excluded Value Countable Value

$ $ $

A. Total Resources Owned by Applicant (From Section III line A)

$______________ B. Amount from Section III Line D

-______________ C. Amount to be transferred to Community Spouse

$______________

__________________________________ _____________________ Caseworker Telephone Number

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