Property Supplement Form

STOP: You do not need to fill out this form if you are applying for no-cost Medi-Cal for children under the age of 19 and/or pregnant women seeking only pregnancy-related care. If necessary, you may be contacted later.

GO: If you're applying for full-coverage Medi-Cal for a family with adults, please fill out this form and identify all of your assets. Which properties are significant to your application will be determined by the county worker. Please contact your worker if you have any questions. Note that owning a property does not exclude you from receiving Medi-Cal benefits.

For each object held in the name of, or for the benefit of, any family member in the residence, check the box under YES or NO. Please read the instructions below each question before proceeding.

The following questions are solely for people who are currently receiving Medi-Cal benefits.

If you choose "YES" for...

Question 1: Please send a copy of the stock or mutual fund certificates with the number of shares indicated on them.

Question 2: Please send the most current statements from your company, financial institution, or brokerage firm detailing the amount of principle and interest you are receiving, as well as the cash worth of your account (after penalties for early withdrawal).

Question 3: Please send copies of the insurance, contracts, trusts, purchase agreements, court orders, and account papers that reflect investments and distributions.

Question 4: Please submit tax returns, invoices, receipts, licenses, profit and loss statements, and other documents as requested.

Question 5: Please include the property's address.

Question 6: Please include the property's address.

Question 7: Please send copies of the mortgage paperwork, as well as the most recent tax assessment, registration, and ownership records.

Question 8: Please supply a copy of the ownership paperwork or the most recent registrations, as well as purchase agreements, sales receipts, or expert valuation estimates. Indicate whether the item is used: on the job (such as a taxi); to travel long distances to work (such as a truck used by a contractor working out of town); to carry the main supply of fuel or water for your home; to transport a disabled or incapacitated family member living in the home; or if it is business property on the submitted verification for each item.

Question 9: Please fax or email copies of sales receipts, appraisals, value estimates, or insurance paperwork.

Question 10: send copies of documents proving the property's value.

Question 11: Please explain and provide verifications as follows.

Question 12: Please explain and attach verifications in the "Additional Information" area at the bottom of this form.

Question 13: Send copies of account statements with current account balances.

Question 14: All court orders, paperwork, and agreements should be sent in duplicate. You do not need to provide copies to your employee if you have previously done so.

Question 15: Send copies of your policies, contracts, and purchase agreements if you answered yes. You do not need to provide copies to your employee if you have previously done so.