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.