| Income Checklist | ||
|---|---|---|
| Income Source | Husband | Wife |
| Social Security | ||
| Pension | ||
| Investment income from assets | ||
| Long term care insurance | ||
| Veterans benefits with Aid and Attendance | ||
| Medi-Cal/Medicaid | ||
| Other | ||
| Total Income | ||
| Total Income (Husband + Wife) | ||
| Less Cost of Care | ||
| Balance | ||
| Resource Checklist | ||
|---|---|---|
| Source | Value/Amount Husband |
Value/Amount Wife |
| Home | ||
| Checking | ||
| Savings/CDs | ||
| Stocks/Bonds/mutual funds | ||
| IRAs | ||
| Annuities | ||
| Other | ||
| Total Sources | ||