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It requests applicant identification and mailing address, prior tax-filing history in the last 60 months, prior residences before entering a nursing home, and payment methods used for nursing care. It also asks about assistance with financial matters, discussions with planners or attorneys, marital status, insurance coverage for nursing home stays, and whether the applicant received inheritances within the last 60 months.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/additional-financial-information-for-long-term-care-applicants/306311/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/additional-financial-information-for-long-term-care-applicants/306311.png","ImageObject",442,249,{"name":88,"@type":89},"Arica Lee","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What applicant information and addresses are required on the form?","Question",{"text":108,"@type":109},"The form requires the applicant’s last name, middle initial, street address, city, and a mailing address if different from the above. It may also require submission details if provided by a hospital or long-term care facility.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What does the form ask about a nursing home resident’s prior living history?",{"text":113,"@type":109},"It asks where the applicant lived prior to moving to the nursing home, listing two places. If already moved, the last two places prior to the current residence must be provided.",{"name":115,"@type":106,"acceptedAnswer":116},"What inheritance and insurance questions are included?",{"text":117,"@type":109},"The form asks whether the applicant inherited money, property, stocks, bonds, or other items within the last 60 months and the amount/value and timing. 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Yes □ No □f YES,for □Property□ Health  \nName                                                        \nAddress                                                \nCity  \n              State  \nRelationship                                        \nPhone:                                                      \n## 6.What is your marital status?\n\n□Single  \n□Married  \nName  \nCity  \n                State  \nIf your spouse is deceased,list the following:  \nDate of Death:  \nThis would include helping you handle things such as checking and savings account;handling your life and healthinsurance payments;handling financial investments such as IRA(s)and Certificate(s)of Deposit;handling yourincome such as Social Security checks,pension checks or annuity payments.This could be a family member,afriend,or a financial advisor or attorney,or power of attorney(POA).  \nIfYES,list the name,address,phone number and relationship of each person who assists you with any of thesematters:  \n·Estate Planning-that is,developing a plan to divide any of your resources between your spouse,members of your familyfriends,church or any other organization or placing your resources in a trust for any of these persons.  \nIf YES,who did you talk to?(This may include a financial planner,attorney,banker,family member,friend,community or service organization,other.)  \nCity  \n       State     \nPhone:  \n□Widow /Widower  \nList the name,address,phone number and Social Security Number (SSN)of your current or most recent spouse:  \nPhone                                                    ","cbCaifPdqPefHYdU","https://ap.wps.com/l/cbCaifPdqPefHYdU","pdf",963850,6,"English","# Instructions\n# Applicant Information\n# Financial Questions\n## Tax Filing History\n## Prior Residences\n## Nursing Care Payment Method\n## Assistance With Financial Affairs\n## Discussions About Nursing Home Need\n## Marital Status\n## Insurance Policies\n## Inheritance Information","[{\"question\":\"What applicant information and addresses are required on the form?\",\"answer\":\"The form requires the applicant’s last name, middle initial, street address, city, and a mailing address if different from the above. It may also require submission details if provided by a hospital or long-term care facility.\"},{\"question\":\"What does the form ask about a nursing home resident’s prior living history?\",\"answer\":\"It asks where the applicant lived prior to moving to the nursing home, listing two places. If already moved, the last two places prior to the current residence must be provided.\"},{\"question\":\"What inheritance and insurance questions are included?\",\"answer\":\"The form asks whether the applicant inherited money, property, stocks, bonds, or other items within the last 60 months and the amount/value and timing. It also asks whether the applicant has an insurance policy that pays while in a nursing home, including policy number and payment recipient details.\"}]","ADDITIONAL FINANCIAL INFORMATION - FOR LONG TERM CARE APPLICANTS | PDF",1789835306]