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					MAP – 4104                                                                                      FMTL-358
(01/04)               CABINET FOR HEALTH & FAMILY SERVICES
                                       ANNUITY TRANSMITTAL



County Name and County #: ______________________________________________
Worker Name: ___________________________________ Caseload Code: ________
Case Name: ____________________________________________________________
Case Number: __________________________________________________________
Application: __________ Recert: _________ Case Chg/PT: _____________________
Application Date: _______________________________________________________
907 KAR 1:650 PROVIDES THAT A DETERMINATION SHALL BE COMPLETED
WITH REGARD TO THE PURPOSE OF THE PURCHASE OF AN ANNUITY IN
ORDER TO DETERMINE WHETHER RESOURCES WERE TRANSFERRED FOR
LESS THAN FAIR MARKET VALUE. YOU MAY BE ASKED TO PRESENT
ADDITIONAL INFORMATION.

Annuitant: _____________________________________________________________
Relationship To Applicant: ________________________________________________
Annuitant's Birthdate: ____________________________________________________
Date of Retirement: ____________________ Age at Retirement: _________________
Date of Last Employment: _________________________________________________
Reason(s) For Purchase of Annuity: __________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Funding Of Annuity: (C.D., savings account, other retirement account, etc.)
___________________________________________________________________________
_____________________________________________________________________----------
--------------------------------------------------------------------------------------------------
This form is a part of the MEDICAID application and I certify that all entries are correct and
true to the best of my knowledge and belief. I understand that this information will be used to
determine eligibility for MEDICAID benefits. I understand that if I give false information or
withhold information in order to receive assistance, I may be subject to prosecution for fraud. I
understand that I have the right to request a Fair Hearing before an impartial hearing officer if
I am dissatisfied with any Agency action.

_______________________________________                         _________________________
(Signature of Applicant, Committee, Representative,                            (DATE)
or Witness if signed by mark)
                                  COMMONWEALTH OF KENTUCKY
                                Cabinet for Health and Family Services
                              Department for Community Based Services

                                            FORMS MANUAL                    FMTL-358

MAP-4104                                ANNUITY TRANSMITTAL                       (1)
                                        Procedural Instructions                8/1/04

*PURPOSE

Form MAP-4104, Annuity Transmittal, is worker-completed in a face-to-face interview or
when it becomes known that the individual has purchased an annuity. The form is used
as a transmittal document to submit annuities to the Department for Medicaid Services
for review.

GENERAL PROCEDURE

The worker completes form MAP-4104, at the time of the interview with the applicant,
Power of Attorney, or representative when making an application for, completing a
recertification or case change. Form MAP-4104 will become a part of the annuity
documentation and should be submitted along with a complete copy of the actual
annuity.

All Adult Medicaid applicants and recipients, who have an annuity that has not been
previously reviewed by the Department for Medicaid Services, must have the annuity
reviewed by DMS. The worker is to obtain a copy of the annuity and submit with form
MAP-4104.

DETAILED PROCEDURES FOR ENTRY ON FORM

1.         Enter the county name and number
2.         Enter worker’s name
3.         Enter caseload code
4.         Enter case name
5.         Enter case number
6.         Indicate the case action (application, recert or case change)
7.         Enter the application date
8.         Enter the annuitant’s name
9.         Indicate the relationship of the annuitant to the applicant
10.        Enter the annuitant’s birthdate
11.        Enter the date of retirement (if retired)
12.        Enter the age at retirement
13.        Enter the last employment
14.        Enter the reason for the purchase of the annuity
15.        Enter the source of the funds used to purchase the annuity
16.        Sign and date the form.
                     COMMONWEALTH OF KENTUCKY
                   Cabinet for Health and Family Services
                 Department for Community Based Services

                                     FORMS MANUAL                      FMTL-358

MAP-4104                         ANNUITY TRANSMITTAL                              (2)
                                 Procedural Instructions                       8/1/04

Ensure the statement has been read or read it to the applicant/recipient and have them
sign and date the form. Provide them with a copy and retain a copy in the case record.
Mail the complete annuity and form MAP-4104 to:

                    Cabinet for Health and Family Services
                    Division of Family Support
                    Medical Support and Benefits Branch
                    275 E. Main St., 3W-D
                    Frankfort, KY 40621

Hold applications pending until a response from DMS is received.        Do not pend
recertifications for DMS response. Once a response is received from DMS on an annuity
that was submitted at recertification or due to a case change take appropriate case
action. Once DMS has reviewed an annuity, no further review is required, unless
changes are made.

				
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