County/City: Fairfax County (059)

STE 232
12011 Government Center
Commonwealth of Virginia
PKWY
Fairfax, VA 22035 Department of Social Services
Phone: (703) 324-7500
Date: 02/16/2022
Case Number: 124149882
Client 1D: 2117114709
Correspondence #: 761015031
Aster Lakew
4083 Championship CT
Annandale, VA 22003

Medicaid Resource Assessment

By completing this form I
request that
Request
countable resources. an assesment be completed to determine the spousal share of
Institutionalized Spouse
Community Spouse
Name: Aster Lakew
SSN #: On File Name: Seyoum Denboba
Address: SSN #: On File
to enw?, onSnl a
Amnanae yA
Date admitted to
Address:4083 Championship CT
a medical institution: Annandale VA 22003
Admitted from where?_
Provide the requested information on
all resources owned,
the month the
institutionalized spouse was admitted to the partially owned, or being bought on the first
institution day of
community-based care. Include real estate (home, land, or to
Medicaid-covered
bonds, savings and checking accounts, certificates buildings), life insurance, cash on hand, stocks or
of deposit, trusts, IRA or
equipment, cemetery plots, burial funds, prearranged Keogh plans, machinery,
properties. funerals, cars, mobile homes, and other real orfarming
personal
Description Owned by
(Type of Resource) Whom Where Located
Value
ChecAiAg ALcount TSon
ASRy Seuam
Saving ACCou+ La 3.13. 2
B own noue seoun Ben auAue 232
mnadlR VA.
oo3
Case #:124149882 Page 1 of 4 H
Correspondence #: 761015031