Dear ____________________:
The Department of Public Welfare (DPW) regulations provide that, when a person is receiving care in an LTC facility, he may give some of his income to his spouse who lives at home. This allowance is intended to help the spouse pay for living expenses.
In order for us to decide whether you are entitled to the allowance, we need to have certain information from you. I would appreciate your answering the following questions and returning this form in the enclosed self-addressed envelope by _______________. Thank you for your cooperation.
1. Do you have any income of your own? (Circle one.) Yes No
2. If yes, please list the detailed information below for each source of income:
|
Amount |
How often do you receive it? |
What is the source? If it is from employment, |
|
$__________ |
_______________________ |
________________________________________________ |
|
$__________ |
_______________________ |
________________________________________________ |
|
$__________ |
_______________________ |
________________________________________________ |
3. Do you own or rent the property you live in? (Circle one.) Own Rent
4. List the expenses you have for the property:
|
Rent per month |
$__________ |
|
Mortgage payment per month |
$__________ |
|
Maintenance payment per month (condominium) |
$__________ |
|
Homeowners’ Insurance per year |
$__________ |
|
Property taxes per year |
|
|
School taxes |
$__________ |
|
City/Township taxes |
$__________ |
|
County taxes |
$__________ |
5. Check the following statement that applies to you:
__ I am billed separately for utilities, including heat.
__ I am billed separately for utilities, except heat.
__ I pay for no utilities, except telephone.
NOTE: Please include proof of the information you have given. You may send pay stubs, receipts, statements from those people who know your situation, such as a landlord, or any other papers that will verify this information. We will send the verification back to you promptly.
Sign here: ________________________________________
Date: ____________________
Updated March 12, 2012, Replacing December 2, 2005