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TEAR HERE

TEAR HERE

SECTION 6

Skip this Section if you are only applying for children under 19 and/or pregnant women (pregnancy related services only).

Otherwise answer for all persons listed in Section 2. 40 Does anyone have cash or uncashed checks?

If “Yes,” list amount here

(See instructions)

41 Does anyone have a checking, savings account, or life insurance? (See instructions) 42 Is there one car or more in the household? (See instructions) 43 Does anyone have a court ordered settlement or judgement? (See instructions) 44 Does anyone have Long-Term Care insurance? (See instructions)

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

45 Does anyone own any items such as stocks, bonds, retirement funds, trusts, real estate, motor vehicles for a business, business accounts, promissory notes, mortgages, deeds of trust, recreational vehicles, burial trusts or funds, annuities, jewelry (not heirloom or wedding), oil or mineral rights? (See instructions)

Yes No

46 Has anyone listed on this form transferred, sold, traded or given away any items such as those listed above in the last 30 months? (See instructions)

Yes No

47 Have any items listed in this section been spent or used as security for medical costs? (See instructions)

Yes No

SECTION 7

Answer only for persons who want Medi-Cal.

Adult 1/Self

Adult 2

Child 1

Child 2

Child 3

49

Place of Birth:

State or Country.

50

U.S. Citizen or National? If “No,” write in date of entry into U.S.

51

Living in a Long-Term Care or Board and Care Facility?

48

Social Security #:

You may be able to receive Medi-Cal even if you do not have a Social Security Number.

Yes No / /

Yes No / /

Yes No / /

Yes No / /

Yes No / /

MO

DAY

YR

MO

DAY

YR

MO

DAY

YR

MO

DAY

YR

MO

DAY

YR

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

CONTINUED

MC 210 08/01 APPLICATION

A3

53

Had medical expenses within the 3 months before the month you applied and want Medi- Cal for those expenses.

54

Lawsuit pending due to accident or injury?

If “Yes,” name of facility:

Do you intend to return home?

Do you intend to return home within six months?

52

Has health/dental or vision coverage?

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