New Burial Exclusion & Designation FormNew Burial Exclusion & Designation Form((current as of 2/1/2010)current as of 2/1/2010)

GPS—

A Guided Practice Series presented by the

OFI Education & Training Section

use the left arrow to move backward

use the right arrow to move forward

To navigate:Open the Power Point in “Slide Show” view

Purpose of this training:Purpose of this training:

Demonstrate the new Burial Exclusion & Designation Form Demonstrate the new Burial Exclusion & Designation Form

The new “Burial Asset Exclusion & Designation” form replaces the old Burial Exclusion worksheet and the Form 985, Designation Form.

ABD Medicaid Burial Exclusion & Designation Form ________________________________ _____________________________ (A/R or Spouse) Date SECTION ONE BURIAL CONTRACT(S): Name of Funeral Home: Date contract was purchased: Is contract paid in full? Yes, list purchase price minus any included sales

tax: No, list what has been paid to date:

(A)

Determine the value of any PAID IN FULL burial space items. List below:

Burial Space Item $Value

Total (B)

Subtract total paid in full burial space items from purchase price or amount paid to date As of: A - B = Value of burial contract (C) (C) SECTION TWO BURIAL FUND(S): Value of any Burial Fund: Designated Value: TOTAL SECTION THREE LIFE INSURANCE: Face Value and Cash Surrender Value of each policy for Non FBR and FBR (circle the type): Face Value Non FBR CSV Non FBR Face Value FBR CSV FBR Total Total Total Total

The form tells what figure to enter on a NON paid in full contract.

Calculate the value of any burial contract.

Carry (c) from section 1 and the totals from section 2 & 3 to the back of the form.

ABD Medicaid Burial Exclusion & Designation Form

SECTION FOUR TOTAL BURIAL ASSETS Total of Burial Contracts (C from Section 1) $ Total of Burial Funds (Designated value) $ Total Face Value of Life Insurance for Non FBR $ Total Value of Life Insurance for FBR $ Total Burial Assets $ SECTION FIVE EXCLUDED BURIAL ASSETS The following assets are being applied toward the burial exclusion allowance of ($10,000/$1500): Type

Company/Bank Name Account/Policy # Amount applied to exclusion:

Burial Contracts Burial Funds Life Insurance Total burial assets applied to exclusion: SECTION SIX COUNTABLE BURIAL ASSETS The following assets cannot be excluded and are being applied to the resource limit:

Company/Bank Name Account/Policy # Amount counted toward resource limit:

Burial Contracts Burial Funds Life Insurance Total burial assets counted toward resource limit: I understand that any designated burial assets that are used for other purposes will be treated as income to me in the month following the month it is determined that the designated assets were used for a purpose other than burial. I further understand that any designated burial assets that are not used for my burial may be subject to estate recovery. ___________________________________ __________________________ Client or Personal Representative Date *********************************************************************************************************** NOTE: If burial funds or burial contract (non-excluded items) are excluded, the client or personal representative must sign this form. Otherwise, the form must be completed and placed in the case record as documentation, but does not have to be signed.

List all burial assets here

Decide what to exclude & list that here.

List here anything you could NOT exclude

Have client or AREP sign if assets include a burial fund or burial contract

Ms. Haynes owns a burial contract with Carmichael Funeral home.

•She is making payments on the contract, so far she has paid $6800.

•The funeral home verifies that she has fully paid for her casket (valued at $2000) and her vault (valued at $550).

• No other burial space items are paid in full.

ABD Medicaid Burial Exclusion & Designation Form SARA HAYNES__________________ _____________________________ (A/R or Spouse) Date SECTION ONE BURIAL CONTRACT(S): Name of Funeral Home: CARMICHAEL FUNERAL HOME Date contract was purchased: 4/8/2000 Is contract paid in full? NO

Yes, list purchase price minus any included sales tax: No, list what has been paid to date:

(A) 6800

Determine the value of any PAID IN FULL burial space items. List below:

Burial Space Item $Value CASKET 2000 VAULT 550

Total (B) 2550

Subtract total paid in full burial space items from purchase price or amount paid to date As of: A - B = Value of burial contract (C) 7/17/XX 6800 2550 (C)4250 SECTION TWO BURIAL FUND(S): Value of any Burial Fund: Designated Value: TOTAL SECTION THREE LIFE INSURANCE: Face Value and Cash Surrender Value of each policy for Non FBR and FBR (circle the type): Face Value Non FBR CSV Non FBR Face Value FBR CSV FBR Total Total Total Total

Ms. Haynes also has a burial fund, it is a $2000 CD.

ABD Medicaid Burial Exclusion & Designation Form SARA HAYNES__________________ _____________________________ (A/R or Spouse) Date SECTION ONE BURIAL CONTRACT(S): Name of Funeral Home: CARMICHAEL FUNERAL HOME Date contract was purchased: 4/8/2000 Is contract paid in full? NO

Yes, list purchase price minus any included sales tax: No, list what has been paid to date:

(A) 6800

Determine the value of any PAID IN FULL burial space items. List below:

Burial Space Item $Value CASKET 2000 VAULT 550

Total (B) 2550

Subtract total paid in full burial space items from purchase price or amount paid to date As of: A - B = Value of burial contract (C) 7/17/XX 6800 2550 (C)4250 SECTION TWO BURIAL FUND(S): Value of any Burial Fund: 2000 Designated Value: 2000 TOTAL 2000 SECTION THREE LIFE INSURANCE: Face Value and Cash Surrender Value of each policy for Non FBR and FBR (circle the type): Face Value Non FBR CSV Non FBR Face Value FBR CSV FBR Total Total Total Total

Ms. Haynes owns a whole life insurance policy with a face value of $5000 and a cash surrender value of $231.

ABD Medicaid Burial Exclusion & Designation Form SARA HAYNES__________________ _____________________________ (A/R or Spouse) Date SECTION ONE BURIAL CONTRACT(S): Name of Funeral Home: CARMICHAEL FUNERAL HOME Date contract was purchased: 4/8/2000 Is contract paid in full? NO

Yes, list purchase price minus any included sales tax: No, list what has been paid to date:

(A) 6800

Determine the value of any PAID IN FULL burial space items. List below:

Burial Space Item $Value CASKET 2000 VAULT 550

Total (B) 2550

Subtract total paid in full burial space items from purchase price or amount paid to date As of: A - B = Value of burial contract (C) 7/17/XX 6800 2550 (C)4250 SECTION TWO BURIAL FUND(S): Value of any Burial Fund: 2000 Designated Value: 2000 TOTAL 2000 SECTION THREE LIFE INSURANCE: Face Value and Cash Surrender Value of each policy for Non FBR and FBR (circle the type): Face Value Non FBR CSV Non FBR Face Value FBR CSV FBR 5000 231 Total 5000

Total 231

Total Total

Now let’s look at the back of the Burial Exclusion & Designation sheet for Ms. Haynes.

ABD Medicaid Burial Exclusion & Designation Form

SECTION FOUR TOTAL BURIAL ASSETS Total of Burial Contracts (C from Section 1) $ 4250 Total of Burial Funds (Designated value) $ 2000 Total Face Value of Life Insurance for Non FBR $ 5000 Total Value of Life Insurance for FBR $ Total Burial Assets $ 11,250 SECTION FIVE EXCLUDED BURIAL ASSETS The following assets are being applied toward the burial exclusion allowance of ($10,000/$1500): Type

Company/Bank Name Account/Policy # Amount applied to exclusion:

Burial Contracts Carmichael FH 4250 Burial Funds Bank of America CD#319-4 2000 Life Insurance Total burial assets applied to exclusion: 6250 SECTION SIX COUNTABLE BURIAL ASSETS The following assets cannot be excluded and are being applied to the resource limit:

Company/Bank Name Account/Policy # Amount counted toward resource limit:

Burial Contracts Burial Funds Life Insurance General Life 147584-AT 231 Total burial assets counted toward resource limit: 231 I understand that any designated burial assets that are used for other purposes will be treated as income to me in the month following the month it is determined that the designated assets were used for a purpose other than burial. I further understand that any designated burial assets that are not used for my burial may be subject to estate recovery. ___________________________________ __________________________ Client or Personal Representative Date *********************************************************************************************************** NOTE: If burial funds or burial contract (non-excluded items) are excluded, the client or personal representative must sign this form. Otherwise, the form must be completed and placed in the case record as documentation, but does not have to be signed.

Section 5: Decide what to exclude

Ms. Haynes would need to sign this form since her assets include a burial contract and a burial fund.

Section 4: List all assets

We exclude the burial contract and the burial fund. Can’t exclude the life insurance because a whole life policy can’t be partially excluded.

Section 6: List anything that could not be excluded.

INTERVIEW RESOURCES 1 - RES1 RES1 01 Month 11 06 8591 10 05 06 01 Client Name BEATRICE CLINE Client ID 000000599 Do you have any of the following: cash, money loaned out, checking, savings, credit union, CD's, stocks, bonds, or secured notes? Del Type Amount V Acct Num Institution Name CH 150.00 CS 1452145-985 BANK OF AMERICA Do you have any of the following: life insurance, pre-paid burial contracts, real estate, or cemetery lots? Del Type Face Amt Cash Amt V Policy Num Company Name BC 6250.00 ? OT EXCLUDED BURIAL ASSETS More Message 0779 01 0779 SHOULD THIS AMOUNT BE ZERO? 15-lett 23-alau 24-del

Excluded assets on RES1

UPDATE REMARKS - REMA REMA 01

(In addition to other resource documentation)

Burial Assets--Ms. Haynes owns:

a burial contract at Carmichael Funeral Home valued at $6800 which includes $2550 in paid for burial space items– value is $4250 a burial fund (CD at Bank of America #319-4) valued at $2000

Life insurance policy #147584 with General Life—FV $5000, CSV $231

Burial contract and burial fund excluded (total exclusion $6250), cash surrender value of insurance counted ($231)

See signed Burial Exclusion & Designation Form 985 in CR

Message More 13-bott

Documentation behind RES1

INTERVIEW RESOURCES 3 - RES3 RES3 01 Month 11 XX 8591 10 05 XX 01 Client Name BEATRICE HAYNES Client ID 000000599 Do you have any of the following: safety deposit box, business holdings, non- home consumption produce, livestock, or other valuables? ----------------- Other Property ------------------ Del Type FMV V Encumb V Annl Rate V Return OC 231.00 OT More Message 15-lett 24-del

Included assets on RES3 (If there’s a FS case these can be entered as “MO”)

UPDATE REMARKS - REMA REMA 01

(In addition to any other resource documentation)

Burial Assets--Ms. Haynes owns:

a burial contract at Carmichael Funeral Home valued at $6800 which includes $2550 in paid for burial space items– value is $4250 a burial fund (CD at Bank of America #319-4) valued at $2000

Life insurance policy #147584 with General Life—FV $5000, CSV $231

Burial contract and burial fund excluded (total exclusion $6250), cash surrender value of insurance counted ($231)

See signed Burial Exclusion & Designation Form 985 in CR

Message More 13-bott

Documentation behind RES3 (just a copy & paste from RES1)

There are many additional examples in the “Train Track” for Burial Assets.

You can find this and many other helpful guides on our website at “gadfcs.org/ofi”

Thank you for completing this desk training.

Have a great day!