DHS-4574-B (Rev. 5-16) Previous edition obsolete. 1

ASSETS DECLARATIONPATIENT AND SPOUSE

Michigan Department of Health and Human Services(Skip if no spouse)

FOR OFFICE USE ONLYBeneficiary Name

Client ID

Case Number

County District Section Unit Specialist

PLEASE PRINTPatient’s Name (First, Middle, Last) Phone No. of Nursing Home Spouse’s Name (First, Middle, Last) Spouse’s Phone No.

Address of Nursing Home (Number, Street, Rural Route) Spouse’s Address (Number, Street, Rural Route)

City State Zip Code City State Zip Code

Patient’s Birthdate (Mo/Day/Yr) Patient’s Social Security Spouse’s Birthdate (Mo/Day/Yr Spouse’s Social Security*

This form asks questions about the property or assets owned by you and/or your spouse. This information is needed to determine your eligibility for Healthcare Coverage and the amount of assets that can be protected for the benefit of your spouse. Answer the following questions by providing information about all assets owned by you and/or your spouse as of _________________________. Include assets you or your spouse own jointly with family or other persons.

ASSETS1. Do you and/or your spouse have any assets (include assets held jointly)?

c Yes 4Check all types of assets your household has and complete the table c No

c Checking/draft account c Money market accounts c Savings/share accounts

c Certificates of Deposit (CD) c Christmas club accounts c Patient trust fund

c Case on hand or in safe deposit c Savings, bonds, stocks or mutual funds c IRA, KEOGH, 401K or DeferredCompensation account(s)

c Trust or Annuity c Land contract, mortgage or othernotes payable to household member

c Real estate (including place you live)

c Life estate/life lease c Burial plot(s), casket, etc. c Tools, equipment, livestock or crops

c Life insurance c Other Assets ___________________ c Health Savings Account

c Burial trust/funeral contract(s)Owner(s)of asset(s)

Type(s)of Asset(s)

Balanceamount of value

Name and address(bank, insurance company, etc.)

Account/policynumber, etc.

AUTHORITY: 42 CFR Part 435.COMPLETION: Voluntary.PENALTY: No Healthcare Coverage.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

*Optional if the community spouse is not requesting assistance.

DHS-4574-B (Rev. 5-16) Previous edition obsolete. 2

ASSETS2. Does anyone in your household have any vehicles?

c Yes 4Check all types of assets your household has and complete the table c No

c Car c Truck c Boat c Camper/trailer c Motorcycle c RV c Other Vehicle

Owner(s)(As shown on vehicle title

or registration) Year Make/Model Amount Owed

3. Has anyone in your household:

• sold or given away property, land, vehicles, stocks, bonds, savings, cash, checking, income, etc., closed any accounts or removed or added a name on any asset within the last 60 months?

c Yes 4Who:

c No

• filed a pending lawsuit which may bring money, property, etc.? c Yes 4Who:

c No• received a one-time cash payment (such as worker’s compensation,

lottery winnings, insurance settlement, lawsuit award, etc.) within the last 60 months?

c Yes 4Who:

c No

• or has anyone acting for any household member, ever put any money, lawsuit settlement, income or assets in a trust, annuity or similar legal device?

c Yes 4Who:

c No

AFFIDAVITI swear or affirm that all the information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance than I am entitled to, I can be prosecuted for fraud.

Estate Recovery. I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some or all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not. Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualifies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call 800-642-3195.

Signature (Patient or Representative) Date (Month, Day, Year)

Two Witnesses OnlyIf Signed by Mark X

Signature of First Witness Signature of Second Witness

NOTE: If you signed this application on behalf of someone else, complete the information below. Name (First, Middle, Last) Phone Number Relationship to Patient

Street Address City State Zip Code

EXHIBIT A ADMISSIONS

Joe T. Doe was admitted to Arbor Manor on August 10, 2006. Attached is a

statement from Arbor Manor.

ARBOR MANOR September 11, 2006 To Whom It May Concern: This letter is to confirm that Joe T. Doe was admitted to Arbor Manor on August 10, 2006. Sincerely, Medical Records Mary Doe

EXHIBIT B STOCKS

On August 10, 2006, Joe and Jane Doe owned the following stocks.

Attached is documentation.

Company No. Shares Amount ABC Energy 1000 $ 50,000.00

XYZ Mill 1000 $ 50,000.00

Total $100,000.00

STOCK CERTIFICATE ABC ENERGY NUMBER SHARES 1234 1000 THIS CERTIFIES THAT **Joe and Jane Doe** IS THE OWNER OF **1,000** FULLY PAID AND NONASSESSABLE SHARES OF COMMON STOCK

STOCK CERTIFICATE XYZ MILL NUMBER SHARES 1234 1000 THIS CERTIFIES THAT **Joe and Jane Doe** IS THE OWNER OF **1,000** FULLY PAID AND NONASSESSABLE SHARES OF COMMON STOCK

EXHIBIT C HOMESTEAD

On August 10, 2006, Joe and Jane Doe owned a homestead. This is an

exempt asset pursuant to BEM Item 400, at 32–34. Attached is a copy of

the quitclaim deed.

QUITCLAIM DEED The Grantor: whose address is: quitclaim(s) to: whose address is: the following described premises situated in the Township of Sumner, County of Gratiot, State of Michigan, and legally described as: for the consideration of NO DOLLARS. This conveyance is exempt from the Real Estate Transfer Tax under the provisions of Section 5(a) of Act No. 134 of the Public Acts of 1966, as amended, and Section 6(a) of Act No. 330 of the Public Acts of 1993, as amended. Dated this ____ day of _______, 20__. Signed by: __________________________ STATE OF MICHIGAN ) COUNTY OF __________ ) On this day of ______, 20__, before me personally appeared ________________, to me known to be the person(s) described in and who executed the foregoing instrument and acknowledged the same as his/her free act and deed. ________________________________ Amy R. Tripp, Notary Public State of Michigan, County of Jackson My commission expires: __________ Acting in Jackson County County Treasurer's Certificate City Treasurer's Certificate Send Subsequent When Recorded Return To: Tax Bills To: Drafted By: Chalgian & Tripp Law Offices, PLLC No Change Amy R. Tripp (P53001) Amy R. Tripp 2127 Spring Arbor Rd. 2127 Spring Arbor Rd. . Jackson, MI 49203 Jackson, MI49203 517/787-7600 Drafter has not examined title to the property

Tax Parcel # Recording Fee Transfer Tax *TYPE OR PRINT NAMES UNDER SIGNATURES.

EXHIBIT D

VEHICLE

On August 10, 2006, Joe and Jane Doe owned a 2001 Oldsmobile Aurora.

This is an exempt asset pursuant to BEM Item 400, at 38. Attached is the

title.

CERTIFICATE OF TITLE *FULL RIGHTS TO SURVIVOR*

YEAR MAKE MODEL VEHICHLE IDETIVIATION NO. 2001 OLDSMOBILE AURORA 0A1BC23456DE7890123 BODY STYLE WT ODOMETER ISSUE DATE TITLE NO. TWO-DOOR 20 0001006 09/10/06 123A4567 z MAILING ADDRESS 1234 LAKE JACKSON, MI 49201 OWNERS NAME AND ADDRESS JOE AND JANE DOE 1234 LAKE JACKSON, MI 49201

EXHIBIT E CHECKING ACCOUNT

On August 10, 2006, Joe and Jane Doe had one checking account at ABC

Bank (#00002) with a balance of $70,000. Attached is their bank statement.

ABC BANK Account Verification Letter

September 11, 2006 To: Law Office We certify that account #00002 is maintained in the name of Joe and Jane Doe at ABC Bank. At the end of the business day on August 10, 2006, the checking account had a balance of $70,000. Sincerely, Account Services Mary Doe

DHS-4574 (Rev. 5-16) Previous edition obsolete.

APPLICATION FOR HEALTH CARE COVERAGE PATIENT OF NURSING FACILITY

Michigan Department of Health and Human Services

FOR OFFICE USE ONLYBeneficiary Name

Client ID

Case Number

HELP IS AVAILABLE County District Section Unit Specialist

The Michigan Department of Health and Human Services must help all persons fill out the application, when requested. If you need help, please call or visit your specialist or the office named below. If you need an interpreter, the Department will provide one free of charge or you may use one of your choice. If you are refused help in filling out the application, call 855-275-6424 or 855-789-5610.

Do you need the Department to provide an interpreter to help you at the interview? c Yes c NoIf yes, what language? _____________________

El Michigan Department of Health and Human Services (MDHHS) no discrimina contra ningún individuo o grupo a causa de su raza, religión, edad, origen nacional, color de piel, estatura, peso, estado matrimonial, información genética, sexo, orientación sexual, identidad de sexo o expresión, creencias políticas o incapacidad.

PLEASE READ CAREFULLYFOR NURSING FACILITY PATIENTS ONLY

Complete this form if you are in a nursing facility. Please read each item carefully before you answer it. The answers you give will be used to determine if you are eligible for health care coverage. Be sure to sign your name on pages 2 and 4.You can apply for health care coverage by mailing or having someone take this form into your local Michigan Department of Health and Human Services (MDHHS) office. Your application must be approved or denied within:• 45 days, or• 90 days if disability is a factor in determining your health care coverage eligibility.Use DCH-1426, Application for Health Coverage and Help Paying Costs, if other family members want help with medical expenses.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

LOCAL OFFICE:

AUTHORITY:COMPLETION:PENALTY:

42 CFR PART 435.Voluntary.No Healthcare Coverage.

El Michigan Department of Health and Human Services debe ayudar a todas las personas a completar la aplicacion cuando asi lo piden. Si usted necesita ayuda, por favor llame o visite a su especialist o la oficina el nombre debajo. Si necesita un interprete, el departmeto le proporcionará uno gratis o usted puede usar uno de su eleccion. Si usted es negado ayuda para completar la aplicacion, puede llamar al 855-275-6424 o 855-789-5610. ¿Necesita que el Departamento proporcione un interprete para que le ayude en la entrevista? c si c noSi dice que si, ¿en que idioma? __________________

عندما یطلب منھم ذلك. ،لوالیة میشیغان مساعدة جمیع االشخاص لملء االستماراتالصحیة واالنسانیة یجب على ادارة الخدماتالذي ینظر بحالتك او المكتب الوارد اسمھ ادناه . أذا كنت بحاجة إذا كنت بحاجة الى المساعدة، یرجى االتصال او زیارة االخصائي

أو باستطاعتك اختیار من ترغب. اذا تم رفض مساعدتك بملء الطلب، الى مترجم ، ستقوم االدارة بتوفیر مترجم لك بدون مقابل .855-789-5610او 855-275-6424یمكنك االتصال على الرقم التالي :

. ال نعم ؟ ة ان توفر لك مترجما كي یساعدك اثناء المقابلةھل ترین من االدار

____________________؟ كلم بھا إذا اجبت بنعم فما ھي اللغة التي تت

DHS-4574 (Rev. 5-16) Previous edition obsolete.

FOR OFFICE USE ONLY

NOTES

DHS-4574 (Rev. 5-16) Previous edition obsolete. 3

Note: This application requests information about the patient in the nursing facility. The words “You” and “Your” refer to the patient.

1. Patient’s Name (First, Middle, Last) 2. Name of Nursing Facility

3. Address of Nursing Facility City State Zip Code

4. Phone No. of Nursing Facility 5. County 6. Birthdate 7. Sex 8. Social Security Number

9. Marital Status: c Never married c Married c Separated c Divorced c Widowed10. Date of Nursing Facility Admission 11. Address where you lived before you entered the nursing facility

12. If married, tell us about your spouse and all persons living with your spouse.If not married, tell us about your children under age 18 living in your home.

Name Date of Birth Social Security Number* Relationship to you

If you have a court-appointed guardian/conservator, enter information below:

13. Name of Guardian/Conservator Phone Number Do you pay guardian/conservator expenses? c YES c NO

Guardian’s/Conservator’s Address City State Zip Code

YES NO YES NO14. Have you ever applied for or received

assistance in Michigan? c c

21. Do you have unpaid medical expenses for services provided in the last 3 months? c c

15. Have you received money or benefits such as Medical Assistance from another state in the last 30 days?

c c

22. Do you pay health insurance premiums? c c

23. Do you have Medicare Coverage?Do you need help paying premiums?

cc

cc

16. Are you a U.S. citizen or U.S. national? c c 24. Are you covered by a health, hospital, or long-term care insurance policy or were you covered in the last 3 months? c c

17. If you are not a U.S. citizen or U.S. national, do you have eligible immigration status? If Yes:a. Immigration document type ______________ b. Document ID number ___________________ c. Have you lived in the U.S. since 1996? c cd. Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military? c ce. U.S. entry date ______________________

25. Has a court ordered anyone to pay your medical expenses or provide health insurance for you? c c

26. Have you had an accident or work-related illness or injury resulting in medical costs that may be paid by another person or an insurance company?

c cEnter your racial heritage from codes below. If you are multiracial, enter all the codes that apply (answering is voluntary) I = American Indian, A = Alaskan Native, S = Asian, B = Black or African American, P = Native Hawaiian or Other Pacific Islander, W = White_____________________________

18.

27. Have you set up a plan or entered into a contract, such as a life care contract, that will pay for your medical care?

c c

19. Check the box if you are Hispanic or Latino (answering is voluntary). c

28. Is there a plan for you to return home within six months from the date of admittance? c c

20. Are you a veteran or the spouse, dependent or parent of a veteran? c c

*Optional if the community spouse and/or children are not applying for Healthcare Coverage.

DHS-4574 (Rev. 5-16) Previous edition obsolete. 4

29. Assets: Complete the assets section by providing the requested asset information for you and your spouse. List your assets and your spouse’s assets. Include assets you own jointly with family or other persons, including your spouse. Include assets your spouse owns jointly with you, family or other persons. Each item must be answered YES or NO. If answered YES, enter amount or current value and owner(s).Type of Asset YES NO Amount or Value Owner(s) of AssetHas anyone in your household received a federal tax refund in the last 12 months?Cash on hand, in a safety deposit box or patient trust fundHome, life estate/life lease

Real estate, not your home

Mortgage, land contract or other notes payable to youSavings bonds or money market funds

Stocks or mutual funds

Pension, IRA, KEOGH, 401K or deferred compensation account(s)Trust funds

Life Insurance

Annuity

Cars, vans, trucks, campers, boats, snow-mobiles, other vehiclesTools, equipment, livestock, or crops

Funeral contracts

Burial plot, casket, etc.

Health Savings Account

Are there any other assets? (Please Explain)

Checking/Draft Accounts — Savings/Share Accounts — Certificates of Deposit

Name(s) on the Account Name and Address of BankCredit Union, Savings and Loan

Account Number Balance

YES NO30. Have you received a one-time cash payment in the last 60 months (5 years) such as an insurance

settlement, lawsuit award, worker’s compensation, lottery winnings, etc.?. . . . . . . . . . . . . . . . . . . . . c c

31. Do you have a pending lawsuit that may bring property or money to you?. . . . . . . . . . . . . . . . . . . . . c c

32. Within the last 60 months (5 years) have you or a joint owner or other person whose name is also listed on the asset:• sold, given away, or transferred ownership in any asset such as those listed above? . . . . . . . . . . c c

• removed or added a name on any asset such as those listed above? . . . . . . . . . . . . . . . . . . . . . . c c

33. Have you or someone acting for you ever put any money, income, lawsuit settlement or assets in a trust, annuity or similar device? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c c

DHS-4574 (Rev. 5-16) Previous edition obsolete. 5

34. Income: Include income for yourself and everyone listed in question 12.Is anyone employed or self-employed? c YES c NO If YES, complete the following for each employed person.Persons employed or

self-employedEmployer name Wages before

deductionsHow often paid: weekly,

every 2 wks, monthly, other$

$

Every item below must be answered YES or NO.Type of Income YES NO Amount Whose IncomeSocial Security Benefits (RSDI) Claim #

Social Security Benefits (RSDI) Claim #

Supplemental Security Income (SSI)

Supplemental Security Income (SSI)

Retirement Benefits

Veterans Benefits

Disability Benefits

Rental Income

Worker’s Compensation

Child Support

Unemployment Compensation

Military Allotments

Gaming Distributions (Casino Profit Sharing)

Is there any other income? (Please explain)

35.Address where your spouse lives Spouse’s Phone Number

City State Zip Code County

Household Expenses Check YES or NO and write in the answer about you and/or your spouse’s home.YES NO AMOUNT HOW OFTEN PAID

Do you and/or your spouse have a rent, mortgage or other shelter expense?

Do you and/or your spouse have the following expenses separate from rent or mortgage:• Renter’s Insurance

• Property Taxes

• Mobile Home Lot Rent

• Special Assessments

• Homeowner’s Insurance

• Mortgage Guarantee Insurance

• Cooperative or Condominium Fee

Do you and/or your spouse have an obligation to pay for heat and/or utilities?

DHS-4574 (Rev. 5-16) Previous edition obsolete. 6

ASSIGNMENT OF BENEFITS

Recovery of Medical Costs. I understand that when the Michigan Department of Health and Human Services (MDHHS) pays the cost of hospital, surgical, or medical services, any right to recover costs from a third person or public or private contractor, except Medicare, is transferred to the MDHHS. Payment of any recovery under such right is to be made directly to the State of Michigan — MDHHS.

RELEASES

Social Security Information. I will allow the Social Security Administration to give to the MDHHS all information necessary to determine my eligibility for benefits under the Healthcare Coverage program until the second month following the expiration of my eligibility based on the current application.

Eligibility Information. I understand that the information I have provided will be used to determine my eligibility for Healthcare Coverage only and for purposes of administering the Healthcare Coverage program.

AFFIDAVIT

Under penalties of perjury, I swear that this application has been examined by or read to me, and, to the best of my knowledge, the facts are true and complete. If I am a third party applying on behalf of another person, I swear that this application has been examined by or read to the applicant, and, to the best of my knowledge, the facts are true and complete.

I certify, under penalty of perjury, that all information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance that I am entitled to, I can be prosecuted for fraud. I understand I must report changes in income, assets or health insurance coverage to the department within 10 days of the change.

If you have any questions, contact your specialist or the local MDHHS before signing the application.

I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some of all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not. Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualifies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call 800-642-3195.

IMPORTANT: YOU MUST SIGN THE APPLICATION

I certify that I have received and reviewed a copy of the Acknowledgments that explains additional information about applying for and receiving Healthcare Coverage.Signature (Patient or Representative) Date Two Witnesses only if signed by X Date

1. 2.

Signature (Patient or Representative) Date Two Witnesses only if signed by X Date1.2.

If you are signing this application on behalf of someone else, complete the information below.

Name of person completing application Phone Number Relationship to patient

Street Address City State Zip Code

DHS-4574 (Rev. 5-16) Previous edition obsolete.

PLEASE KEEP THIS PAGE.Tear out along the dotted line.

INFORMATION ABOUT HEALTHCARE COVERAGE

Rules may have changed since this was printed. Check with your local MDHHS office.

“You” and “Your” below refer to the patient. “We” means the Michigan Department of Health and Human Services.

If you need help with past, unpaid medical expenses, Healthcare Coverage may begin three months before you apply. You can have Healthcare Coverage even if you are not a U.S. citizen. Coverage might be limited to just emergency services. There are limits on the amount of income and assets you can have and be eligible for Healthcare Coverage.

Receiving Healthcare Coverage Services

You must tell all your providers (doctors, hospital, pharmacy, etc.) that you have applied for Healthcare Coverage before you receive any new medical services. Not all providers accept Healthcare Coverage. Choose a provider who does accept Healthcare Coverage.

You must give your medical provider a copy of your mihealth card or approval letter as soon as it is received. This letter tells when your eligibility began. Your providers need this information to receive prompt payment for medical services provided to you. This information is needed to issue you a refund if you pay for a Healthcare Coverage service before you received the approval letter.

We might approve Healthcare Coverage for up to 3 months before you applied. If we do, ask your providers to bill Healthcare Coverage for any covered services you received during those months. If you paid for any of these bills before you received the approval letter, ask your health providers if they will refund your money and bill Healthcare Coverage. Providers are not required to do this, but many will.

Your providers must submit your bills to Healthcare Coverage within 12 months after the date you received the services. If they wait more than 12 months, then Healthcare Coverage may not pay the bill unless the delay in billing is because you had to file an appeal to get Healthcare Coverage benefits.

Income

You meet the income test if your income is not enough to pay your medical expenses. Usually you will pay part of your nursing facility expenses and Healthcare Coverage will pay the rest. If you have a spouse or children at home, a portion of your income might be protected for them.

We count income such as Social Security benefits, pensions, rent income and veterans benefits.

Assets

Countable assets must be at or below the $2,000 asset limit at least part of each month for which Healthcare Coverage is requested. If you have a spouse at home:

We count your assets and your spouse’s assets initially. We protect a substantial amount of assets for your spouse. The remainder cannot exceed $2,000 for you to be eligible for Healthcare Coverage.

Once initial eligibility is established, we only count your assets. The asset limit is $2,000.

If your assets are more than the asset limit, you may become eligible for Healthcare Coverage if you use your excess assets to pay some of your medical bills, living expenses, or other debts. You may be asked to verify when and for what purposes you used your excess assets.

Healthcare Coverage might not pay for your care if you or your spouse transfer assets or income for less than fair market value. We look at transfers that occur up to 60 months (5 years) before, or any time after, your first date of application for Healthcare Coverage while in a nursing facility.

Nursing Facility Eligibility (MDCH Publication 726) - explains eligibility for persons in or entering a nursing facility.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

DHS-4574 (Rev. 5-16) Previous edition obsolete.

ACKNOWLEDGMENTSMichigan Department of Health and Human Services

This is your copy of your rights and responsibilities as an applicant for or recipient of Healthcare Coverage benefits. By signing the application you acknowledge that you understood your rights and responsibilities and that you applied only for Healthcare Coverage.

ASSIGNMENT OF BENEFITS

1. Recovery of Medical Costs. I understand that when the Michigan Department of Health and Human Services (MDHHS) pays the cost of hospital, surgical, or medical services, any right to recover costs from a third person or public or private contractor, except Medicare, is transferred to the MDHHS. Payment of any recovery under such right is to be made directly to the State of Michigan - MDHHS.

ACKNOWLEDGEMENTS

2. Non-discrimination. I understand that if I believe I have been discriminated against because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs, I have the right to file a complaint with the: Regional Manager, Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Chicago, IL 60601, 800-368-1019, 800-537-7697 TDD.

3. Reporting Changes. I understand that the department needs to know about changes that may affect my Healthcare Coverage. I will tell the department of any changes within 10 days of the change. I understand that if I intentionally do not do this, I can be prosecuted for fraud or perjury.

The types of changes that MUST be reported are:

• Receipt of or increase in income such as social security, veterans benefits, railroad retirement, pensions, retirement, disability or sick benefits.

• Discharge or move from the nursing facility to another living arrangement.

• Changes in health or hospital insurance coverage or amount of premiums.

• Any accident or work-related illness or injury where medical costs may be paid by another person or an insurance company.

• Another person or an insurance company has agreed to pay my medical expenses or is ordered to by the court.

• Receipt of a sum of money.• Receipt of an inheritance, bank account, or other property or

income from or on behalf of another person.

If you have any doubt about whether you should report a change in circumstances, ask your local MDHHS.

4. Hearings. I understand that if I do not agree with any decision made on any matter concerning my case I have the right to ask for an Administrative Hearing. I understand that I can ask for information about an Administrative Hearing by calling my local MDHHS.

I understand that if I want someone else to request a hearing for me or represent me in a hearing, that person must first have written au-thorization to do so unless that person is my attorney or my spouse. The MDHHS Administrative Hearings must have one of the following:• my original signed statement authorizing the person to

request a hearing, or• a copy of the court order naming the person as my guardian

or conservator.

Otherwise, my hearing request will be denied.

5. Repayment of Benefits. I understand that if I receive more benefits than I am entitled to receive, through my fault, I may have to repay any extra benefits.

6. Immigration Status. I understand that, as part of determining my eligibility for Healthcare Coverage, information about me may be submitted to the Bureau of Citizenship and Immigration Services in order to verify my immigration status.

7. Investigations. I understand that my application might be one of those chosen for a complete investigation and an MDHHS representative might call on me and might contact other people in order to verify my eligibility for assistance.

8. Computer Cross-checking. I understand that, as part of determining my eligibility for Healthcare Coverage, information I give on this application will be verified by computer cross-checking with other public and private agencies.

Wages reported by my employer(s) to the Department of Labor and Economic Growth will be checked against wage information I report to the MDHHS. My Social Security Number will be used to check this information. Throughout the year, my Social Security Number will also be checked with other sources such as the Internal Revenue Service (IRS), Unemployment Compensation, and the Social Security Administration concerning income or assets.

The information obtained through this cross-checking may be verified through collateral contact when discrepancies are found. The information may affect both my eligibility and the level of my benefits.

9. Medical Information. By signing this application, I understand that the MDHHS may get and use* necessary medical information about me or any of my wards or my minor children, including any information relative to HIV, ARC or AIDS, if applicable. This information will only be obtained and used as necessary to determine eligibility for a specific program or for other program administration purposes.

*Some examples of uses are with auditors, caregivers, etc. State law (MCL 333.5131 (8)) provides that a person who shares HIV, ARC or AIDS information except as authorized by this release or by law may be found “guilty of a misdemeanor punishable by imprisonment for not more than 1 year or a fine of not more than $5,000.00, or both, and is liable in a civil action for actual damages or $1,000.00, whichever is greater, and costs and reasonable attorney fees.”

10. Social Security Information. I will allow the Social Security Administration to give to the MDHHS all information necessary to determine my right to benefits under Healthcare Coverage until the second month following the expiration of my eligibility based on the current application.

11. Eligibility Information. I understand that the information I have provided will be used to determine my eligibility for Healthcare Coverage only and for purposes of administering the Healthcare Coverage Program.

12. Estate Recovery. I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some or all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not. Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualifies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call 800-642-3195.

EXHIBIT 1 HEALTH INSURANCE & VITALS

John T. Doe does not have any supplemental health insurance. Attached

are copies of John T. and Jane T. Doe’s Social Security cards, driver’s

licenses, and Medicare cards.

Medicare Card Joe T. Doe 123-45-6789 –A Male Hospital (Part A) 01-01-85 Hospital (Part B) 01-01-85

Social Security Card 123-45-6789 JOE T. DOE Signature:

Driver’s License Joe T. Doe 1234 Lake Jackson, MI 49201 Date of Birth Sex Height Eyes Weight 01-01-31 M 6’1” blue 160

Medicare Card Jane T. Doe 012-34-5678 –A Female Hospital (Part A) 01-01-85 Hospital (Part B) 01-01-85

Social Security Card 012-34-5678 JANE T. DOE Signature:

Driver’s License Jane T. Doe 1234 Lake Jackson, MI 49201 Date of Birth Sex Height Eyes Weight 02-02-31 F 5’1” blue 125

EXHIBIT 2 HOMESTEAD

Joe and Jane Doe own a homestead. This is an exempt asset pursuant to

BEM Item 400, at 32–34. See exhibit C of the Asset Declaration for a copy

of the quitclaim deed.

EXHIBIT 3 VEHICLE

Joe and Jane Doe owned a 2001 Oldsmobile Aurora. This is an exempt

asset pursuant to BEM Item 400, at 38. See exhibit D of the asset

declaration for a copy of the title.

EXHIBIT 4 CHECKING ACCOUNT

Joe and Jane Doe have one checking account at ABC Bank (#00002) with

a current balance of $75,000. Attached is their bank statement.

ABC BANK Account Verification Letter

September 11, 2006 To: Law Office We certify that account #00002 is maintained in the name of Joe and Jane Doe at ABC Bank. At the end of the business day on September 8, 2006, the checking account had a balance of $75,000. Sincerely Account Services Mary Doe

EXHIBIT 5 SOLD ASSET

On September 5, 2006, Joe and Jane Doe sold their stock with ABC

Energy and XYZ Mill. The total surrender value of ABC Energy stock was

$50,000, and the total surrender value of XYZ Mill was $50,000. They

deposited the proceeds of the sold stocks ($100,000) into their ABC Bank

account (#00002). Attached is documentation.

XZY MILL 000000001 0000 LAKEVIEW JACKSON, MI 49203 September 5, 2006 PAY TO THE ORDER OF: Joe or Jane Doe $50,000.00 Fifty-Thousand and No/100 Dollars KL BANK Lansing, MI 48823 FOR: Full surrender of XYZ Mill stock John Smith, President

ABC ENERGY 000001234 1000 BAKER JACKSON, MI 49203 September 5, 2006 PAY TO THE ORDER OF: Joe or Jane Doe $50,000.00 Fifty-Thousand and No/100 Dollars CHOICE BANK Lansing, MI 48823 FOR: Full surrender of ABC Energy stock Mary Smith , President

ABC BANK Account Verification Letter

September 11, 2006 To: Law Office On September 6, 2006, Joe and Jane Doe deposited $100,000 into their joint checking account (#00002). On September 7, 2006, Daniel Doe opened an account as trustee of the Jane Doe Irrevocable Trust dated September 1, 2006. The opening deposit for this new account (#00003) was $95,000. These funds were transferred from Joe and Jane Doe’s checking account (#00002). As of September 8, 2006, Joe and Jane Doe have a balance of $75,000 in their joint checking account (#00002). Sincerely Account Services Mary Doe

EXHIBIT 6 INCOME

Joe and Jane Doe receive the following monthly income: Type Whose income Amount Social Security Joe Doe $1,588.50 Social Security Jane Doe $1,088.50 Total $2,677.00

Your New Benefit Amount BENEFICIARY’S NAME JOE T. DOE How Much Will I Get and When?

• Your new monthly amount (before deduction) is $,1,588.50

• The amount we are deducting for Medicare is $ 88.50 (If you did not have Medicare as of Nov. 20, 2005, or if someone else pays your premium, we show $0.00.)

• The amount we are deducting for voluntary federal tax withholding is $ 0.00

(If you did not elect voluntary federal tax withholding as of Nov. 20, 2005, we show $0.00.)

• After taking any other deductions, we will deposit $1,500.00 into your bank account on Jan. 3, 2006. If you disagree with any of these amounts, you should write to us within 60 days from the date

you receive this letter.

Your New Benefit Amount BENEFICIARY’S NAME JANE T. DOE How Much Will I Get and When?

• Your new monthly amount (before deduction) is $,1,088.50

• The amount we are deducting for Medicare is $ 88.50 (If you did not have Medicare as of Nov. 20, 2005, or if someone else pays your premium, we show $0.00.)

• The amount we are deducting for voluntary federal tax withholding is $ 0.00

(If you did not elect voluntary federal tax withholding as of Nov. 20, 2005, we show $0.00.)

• After taking any other deductions, we will deposit $1,000.00 into your bank account on Jan. 3, 2006. If you disagree with any of these amounts, you should write to us within 60 days from the date

you receive this letter.

EXHIBIT 7 COMMUNITY SPOUSE EXPENSES

Joe and Jane Doe pay property taxes. Enclosed please find copies of the

Summer 2005 tax bill in the amount of $1,231.17 and the Winter 2005

property tax bill in the amount of $726.99.

Joe and Jane Doe pay homeowners insurance through AXY Property and

Casualty Insurance Company. Enclosed please find a copy of their

homeowner's statement in the amount of $655.00 per year.

Joe and Jane Doe pay utilities to Consumers Energy. Enclosed is a copy of

their utilities obligation.