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H. AUXILIARY GRANTS (AG)

 YES  NO 1 Do you live in an Assisted Living Facility, an Adult Foster Care Home, a Nursing Facility, or other institution? If YES, Date Applicant Entered_______________________ City/County and State where you lived before entering the institution ____________________. If outside Virginia, was placement made by a government agency?  YES  NO

 YES  NO 2 Have you applied for or are you applying for supportive housing?

 YES  NO 3 Do you have a spouse who does not live in the home? If YES, enter the Spouse’s Name and address _________________________________________________________________________________________

 YES  NO 4. Have you lived in Virginia for the past 90 days?

 YES  NO 5 Do you owe or did you pay any bills you had in the month of entry into an assisted living facility or adult foster care?

 YES  NO 6. Do you have any unpaid medical bills for the three months before the application month?

Description of Bills Dates of Bills Dates Bills Paid

 YES  NO 7. Do you own any household goods or personal effects worth more than $500, such as silver, fine china, furs, artwork, jewelry, or other items held for their value or as an investment?

Description and Value of Items

 YES  NO 8. Do you have any burial plots, burial arrangements or trust funds for burial?

Owner(s) Number of Plots

Type of Arrangement: Where Value $

Amount Owed $ Date Acquired Qwner(s) Burial contract/agreement type:  Irrevocable  Revocable Trustee/Authority/Funeral Home: Funds Required $ Amount Paid $

Other information:

 YES  NO 9. Does anyone own any personal property, such as campers/trailers, non-motorized boats, utility trailers, tools, equipment, supplies, or livestock?

Owner(s) Type Is this property used in your business or trade, including farming? Value Amount Owed Date Acquired

YES ( ) NO ( )

 YES  NO 10. Does anyone own any real property, including life estates, inherited property, land, buildings, or mobile homes? If YES, do you live there? Check ():  YES  NO

Owner(s) Type YES ( ) NO ( ) Currently rented? YES ( ) NO ( ) Income-producing? YES ( ) NO ( ) Currently for sale? Value Amount Owed Date Acquired

$ $

 YES  NO 11. Does anyone own vehicles, such as cars, trucks, vans, motorboats, motor homes, recreational vehicles, or motorcycles/mopeds?

Owner(s) Type, Make, Model, Year Currently Licensed? Vehicle ID# License # Value Amount Owed How Used Date Acquired

 YES  NO # # $ $

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