asset assessment for medical assistance (ma)...

Minnesota Health Care Programs

Asset Assessment for Medical Assistance (MA) Payment of Long-Term Care (LTC) Services

What is this form for?Fill out this form if all of the following are true:

You received or expect to receive 30 uninterrupted days of long-term care (LTC) services. LTC services include nursing home care or services to help you stay in your home through the Elderly Waiver (EW) or Alternative Care (AC) program.

You are married. Your spouse does not live in a long-term care facility such as a nursing home. Your spouse is not getting services to help him or her stay in their home through the EW, Community Alternatives for Disabled Individuals (CADI), Community Alternative Care (CAC), Developmental Disabilities (DD) or Traumatic Brain Injury (TBI) waiver programs.

We use the information on this form to decide the amount of assets your spouse can keep. We will not count these assets toward your asset limit for Medical Assistance (MA) payment of LTC services.

NOTE: You can still fill out this form if you are not asking for MA at this time. We will give you an estimate of how many assets your spouse can keep. We will keep the form so you do not have to fill it out again when you ask for MA in the future.

What do I need to do with this form?1. Read the Important Information on page B at the back of this form. Tear it off and keep it.

2. Answer all questions on the form. If you need more space, write the number of the question and the answer on a separate piece of paper. Include it with the form.

3. Attach proofs. Proofs we need are on page A at the back of the form.

4. Mail or take the form to your county agency.

Questions?If you have questions or need help, call your county agency. You can ask to meet with a worker. You can also call the Senior LinkAge Line if you are 60 or older at (800) 333-2433 or the Disability Linkage Line if you are a person with a disability at (866) 333-2466.

DHS-3340-ENG 3-11

Attention. If you want free help translating this information, ask your worker or call the number below for your language.

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1-888-468-3787 .

Panja. Ako vam je potrebna besplatna pomo za prevod ove informacije, pitajte vaeg radnika ili nazovite 1-888-234-3785.

Ceeb toom. Yog koj xav tau kev pab txhais cov xov no rau koj dawb, nug koj tus neeg lis dej num (worker) lossis hu 1-888-486-8377.

. , 1-888-487-8251.

Hubaddhu. Yoo akka odeeffannoon kun sii hiikamu gargaarsa tolaa feeta tae, hojjataa kee gaafaddhu ykn lakkoofsa kana bilbili 1-888-234-3798.

: , : 1-888-562-5877.

Ogow. Haddii aad dooneyso in lagaa kaalmeeyo tarjamadda macluumaadkani oo lacag laaan ah, weydii hawl-wadeenkaaga ama wac lambarkan 1-888-547-8829.

Atencin. Si desea recibir asistencia gratuita para traducir esta informacin, consulte a su trabajador o llame al 1-888-428-3438.

Ch . Nu qu v cn dch thng tin ny min ph, xin gi nhn-vin x-hi ca qu v hoc gi s 1-888-554-8759.

LB2-0001 (10-09)

This information is available in alternative formats to individuals with disabilities by calling (651) 4312670 or (800) 6573739. TTY users can call through Minnesota Relay at (800) 6273529. For SpeechtoSpeech, call (877) 6273848. For additional assistance with legal rights and protections for equal access to human services programs, contact your agencys ADA coordinator.

ADA3 (5-09 )

*DHS-3340-ENG*DHS-3340-ENG 3-11

Minnesota Health Care Programs

Asset Assessment for Medical Assistance (MA) Payment of Long-Term Care (LTC) Services

Office Use OnlyDATE RECEIVED CASE NUMBER WORKER NUMBER

DATE OF BIRTH SE

lX

lSOCIAL SECURITY NUMBER PHONE NUMBER COUNTY

M F

STREET ADDRESS CITY STATE ZIP CODE

OPTIONAL RACE INFORMATION l Asian

l Black/African American l American Indian/Native Alaskan HISPANIC OR LATINO? l Yes No Pacific Islander or Native Hawaiian White l

SPOUSES FIRST NAME

lMI LAST NAME

l

DATE OF BIRTH SOCIAL SECURITY NUMBER PHONE NUMBER COUNTY

SPOUSES STREET ADDRESS (if different) CITY STATE ZIP CODE

OPTIONAL RACE INFORM TION

l AsianA l Black/African American l American Indian/Native AlaskanHISPANIC OR LATINO?

Yes No Pacific Islander or Native Hawaiian White

Name and address

We need information about assets you and your spouse owned or co-owned on the date you started to receive 30 days of uninterrupted long-term care (LTC) services.

This date is the Asset Assessment Effective Date.

Answer the questions below to help you determine your Asset Assessment Effective Date. Contact your county agency if you need help determining this date.

FIRST NAME MI LAST NAME

l l l l

Are you living in a long-term care facility (LTCF) such as a nursing home? No Yes fill in below

l l

Enter the day you first lived in the LTCFDATE

A.

Were you in the hospital before you went to the LTCF? l lIF YES, ENTER THE DAY YOU WENT INTO THE HOSPITAL

B. No Yes

See Required Proofs on Page A If you need more space, write the question number and the answer on a separate piece of paper.

1

2


Have you lived in an LTCF before for 30 days or more? Count time spent in a hospital if entered the LTCF directly from the hospital. l No l Yes fill in belowEnter the day you first lived in the LTCF (If you had more than one stay in an LTCF for 30 days or more, enter the first day of your earliest stay.)

DATE

C.

Have you had a Long Term Care Consultation (LTCC) in the past 60 days that says you need a nursing facility level of care? You may need to contact your LTCC/Case Manager to answer this question. l No l Yes fill in below

Enter the Assessment Date from Section I on your Community Support PlanDATE

D.

Have you ever received an LTCC that said you needed a nursing facility level of care and you received services that lasted 30 days or more through either: the Elderly Waiver (EW) or Alternative Care (AC) program, or a licensed provider whose services would qualify for payment through the EW or AC programs?You may need to contact your LTCC/Case Manager to answer this question. l No l Yes fill in belowEnter the Assessment Date from Section I on your Community Support Plan (If you had more than one Support Plan that meets these criteria, enter the earliest date.)

DATE

E.

Were you in the hospital or in an LTCF when you received the LTCC and immediately began receiving services upon discharge from the hospital or LTCF? l No l Yes

IF YES, ENTER THE DATE YOU WENT TO THE HOSPITAL OR LTCF

F.

Enter the earliest date from A, B, C, D, E or F above DATE G.

The date you have entered in G above is your Asset Assessment Effective Date.

Have you completed an Asset Assessment form before? l No Complete the rest of this form l Yes fill in below

Enter the county or state where the Asset Assessment form was completed.COUNTY OR STATE

STOPIf you answered Yes to the above question, do not complete the rest of this form.

Mail or take this form to your county agency.

3


ENTER YOUR ASSET ASSESSMENT DATE (from Line G on page 2) Answer the following questions about assets you and your spouse owned or co-owned on the Assets Assessment Effective date entered.

1. How much cash did you or your spouse have on hand, in a safety deposit box, at home and at the facility where you or your spouse lives on your asset assessment effective date?

$

2. Did you or your spouse have savings or checking accounts, money market accounts or certificates of deposit on your asset assessment effective date? l No l Yes fill in below

Owner(s) name Type of account Bank name and address Account number

3. Did you or your spouse have stocks, bonds or retirement accounts on your asset assessment effective date? l No l Yes fill in below

Owner(s) name Type of investment Company or bank name and address Account number

4. Did you or your spouse own or co-own houses, life estates, condominiums, summer or winter homes, cabins, land, buildings, mobile homes, time shares, rental properties or any real estate on your asset assessment effective date? l No l Yes fill in below

Owner(s) name Type of property Property addressDo you or your spouse

live here all year?

l Yes l No

l Yes l No

l Yes l No

4


5. Did you or your spouse own or co-own promissory notes, contacts for deed or other property agreements on your asset assessment effective date? l No l Yes fill in below

Owner(s) name Type of asset

6. Did you or your spouse have any vehicles in your name on your asset assessment effective date? Include cars, trucks, vans, motorcycles, motor homes, campers, boats, snowmobiles, all-terrain vehicles, etc.

l No l Yes fill in belowOwner(s) name Type of vehicle Year/Make/Model

7. Did you or your spouse own or have an interest in a trust or annuity on your asset assessment effective date? l No l Yes fill in below

Owner(s) name Type

8. Did you or your spouse have life insurance on your asset assessment effective date? l No l Yes fill in below

Owner(s) name Policy number Insurance company name and address

9. Did you or your spouse have a prepaid burial account or burial trust on your asset assessment effective date? Include revocable and irrevocable accounts, insurance-funded burials, annuity-funded burials, Cremation Society agreements, burial spaces, burial space items and other funds designated for burial.

l No l Yes fill in belowOwner(s) name Type of burial Company or bank name and address

5


10. Did you or your spouse have assets used for self-employment on your asset assessment effective date? Include tools, machinery, farm implements, inventory, etc. l No l Yes fill in below


Was the business in operation on the asset assessment date? l Yes l No

IF NO, WHY NOT?

11. Did you or your spouse own or co-own any other assets you have not listed on your asset assessment effective date? l No l Yes fill in below


12. Did you or your spouse live in a Continuing Care Retirement Community on your asset assessment effective date? l No l Yes

I declare that I have read and understand the information on this form. I believe all of the information entered on this form is true and correct.

YOUR SIGNATURE SPOUSES SIGNATURE DATE

SIGNATURE OF PERSON ACTING ON YOUR BEHALF RELATIONSHIP DATE

THEIR ADDRESS THEIR DAYTIME PHONE NUMBER

Keep this page.

A

Required Proofs

Send proof of how much each asset listed on this form was worth on your asset assessment effective date. Proof can be any of the following:

Bank accounts Bank statements or a written statement from the bank showing the balance or value of accounts.

Stocks, bonds and retirement accounts Copies of bonds, stock ownership statements, retirement account statements or other documents showing the value.

Real estate Property tax statement. Include documents showing the loan balance owed against the property.

Promissory notes, contracts for deed or other property agreements Copies of promissory notes, contract for deed or other property agreement documents.

Vehicles Documents showing the loan balance owed against the vehicle.

Trusts and annuities Copies of trust documents, documents showing an accounting of the trust corpus for each trust and annuity contracts.

Life insurance Life insurance statements showing the face and cash surrender value.

Burial contracts Burial contract and statement of goods and services from the company or funeral home that holds the contract.

Self-employment assets Documents showing the value of assets. Include documents showing the loan balance owed against each asset.

Continuing Care Retirement Community entrance fee Documents showing the available amount of the entrance fee.

Other assets Documents showing the value of assets. Include documents showing the loan balance owed against the asset.

Send proof of your Asset Assessment Effective Date.

This may be a copy of your hospital admission form, hospital bill showing the admission date, documents from the nursing home, your Community Support Plan or bills showing the date and type of service.

You may sign a Release of Information form so a county worker can help you get the proofs.

Send copies of proofs. Do not send original documents.

Keep this page.

B

Important Information

What is an Asset Assessment? An Asset Assessment determines the total value of assets you and your spouse own on a specific date.

We use the information on the Asset Assessment form to decide the amount of assets your spouse can keep. We will not count the assets your spouse can keep toward your asset limit for Medical Assistance (MA) payment of LTC services.

When should I complete an Asset Assessment? You can ask to complete an Asset Assessment any time you expect to receive 30 uninterrupted days of LTC services. You must complete an Asset Assessment if you are asking for Medical Assistance (MA) payment of LTC services in a long-term care facility such as a nursing home or through the Elderly Waiver (EW) or Alternative (AC) program.

What assets should I list on the Asset Assessment?

Assets in your name Assets in your spouses name Assets in both you and your spouses names

Does my home count as an asset when completing the Asset Assessment? Usually, your home does not count as an asset when completing an Asset Assessment. Other assets that do not count include:

Personal property and household goods One vehicle Capital assets needed to operate a trade or business Money set aside for a burial space and burial space items for you, your spouse and other members of your immediate family.

Retirement annuities funded by a pension fund or retirement plan unless you can get all or part of the funds.

Certain assets owned by an American Indian.

You must tell us about all assets you and your spouse owned or co-owned on your asset assessment date. A worker will determine if an asset does not count.

What assets count? Counted assets include but are not limited to:

Cash Bank accounts (savings, checking, certificates of deposit, money markets, credit union accounts, etc.)

Stocks and bonds IRAs and retirement accounts Cash surrender value of life insurance policies if the face value of all policies is more than $1,500

Contracts for deed Certain trust funds Life estate interests Annuities in the accumulation phase If you have more than one vehicle, the other vehicle(s) count as assets. Vehicles include cars, vans, motor homes, motorcycles, trucks, campers, etc.

Boats, trailers, machinery, snowmobiles, all-terrain vehicles, etc.

Lake homes, cabins, summer and winter homes, time-shares, life estates, etc.

You must tell us about all assets you and your spouse owned or co-owned on your asset assessment date. A worker will determine if an asset counts.

What happens after I complete the Asset Assessment form?Give the completed form to your county agency. A worker will look at the information on the form and decide the amount of assets your spouse can keep. You will get a letter telling you how much this is.

Can the results of the Asset Assessment change? Results can change if:

Other assets are discovered that were not included in the assessment. Report asset changes to the county agency. We will decide if these assets change the results of the asset assessment.

You asked for an Asset Assessment because you expected to receive 30 uninterrupted days of LTC services but you did not receive LTC services for 30 uninterrupted days. You will need to complete a new Asset Assessment when you ask for MA payment of LTC services again. You will have a new asset assessment effective date.

Rev: 4/12/11 Health Care Training

You also requested the balance on the loan for your 2004 Buick LeSabre as of July 12, 2006. As of that date you owed $3,000 on that loan. Please contact me if you have any questions.

Joe E. Banker

Joe E. Banker Branch Vice President

Wells Fargo 846 Johnson Parkway St. Paul, MN 55106 (800) 869-3557

8/15/2006 Padma and Aman Das 1666 White Bear Avenue St. Paul, MN 55106 Dear Mr. and Mrs. Das, Per your written request, please find the balance of the following accounts on July 12, 2006. No deposits were made into any of these accounts prior to or on this date. Account Number: 8800020001-SV $ 1,200.00 Account Number: 880220022-CK $ 12,854.22 Account Number: 45869521-SV $ 1,800.00 Account Number: 4587965-CD $ 4,958.32

https://www.wellsfargo.com/


Padma Das Lincoln Financial Group PO Box 7880 Fort Wayne, IN 46801

07/01/2006 Re: 95-489656

Padma Das 1666 White Bear Avenue St. Paul, MN 55106 Dear Ms Das: This monthly statement indicates the current value of your annuity contract with Lincoln Financial Group. Funds Deposited: $50,000.00 Interest Earned To Date: $35,000.00 Total Cash Surrender Value: $85,000.00 Beneficiary: Estate of Padma Das This contract cannot be assigned and is an irrevocable election. If you have questions or need assistance, please contact us at 1-800-965-5500, extension *5432, Monday through Friday 8:00a.m. to 6:30p.m. EST. Sincerely, Erin Costello Erin Costello Annuity Operations


Padma Das Lincoln Financial Group PO Box 7880 Fort Wayne, IN 46801

08/01/2006 Re: 95-489656

Padma Das 1666 White Bear Avenue St. Paul, MN 55106 Dear Ms Das: This monthly statement indicates the current value of your annuity contract with Lincoln Financial Group. Funds Deposited: $50,000.00 Interest Earned To Date: $35,000.00 Total Cash Surrender Value: $85,000.00 Beneficiary: Estate of Padma Das This contract cannot be assigned and is an irrevocable election. If you have questions or need assistance, please contact us at 1-800-965-5500, extension *5432, Monday through Friday 8:00a.m. to 6:30p.m. EST. Sincerely, Erin Costello Erin Costello Annuity Operations

BigBusinessEnterprise3800HiawathaBoulevardMinneapolis,MN55406

8/15/20061666WhiteBearAvenueSt.Paul,MN55106DearAmanD.Das,PleasefindtheinformationyourequestedaboutyourpensionfundasofJuly12,2006.PensionFundBalance:$100,000.000Thepensionfundyourpensionpaymentsaredrawnfromcannotbeaccessedforanyreason.Weagainthankyouforyourtimespentasanoutstandingemployee!Sincerely, C M Ringerup C.M.RingerupPresident

Rev. 9/16/09 Health Care Training

Nelson Funeral Home 400 13th Ave. N.E. Minneapolis, MN 55418 612-386-3725

Irrevocable Funeral Trust Agreement For the benefit of ______Aman Das___________ (BENEFICIARY of Trust) PURCHASER/BENEFICIARY under this Agreement must be the Beneficiary of the Trust This Irrevocable Funeral Trust Agreement is made by and between the undersigned contract purchase and beneficiary of funeral services and/or merchandise (hereinafter PURCHASER/BENEFICIARY) and the funeral establishment as defined by and licensed pursuant to Minnesota Statute 149.08 and designated below as TRUSTEE. The purpose of this Irrevocable Funeral Trust Agreement is to set forth in advance certain arrangements regarding burial expenses and/or expenses for burial space items to be incurred on behalf of PURCHASER/BENEFICIARY. The services and merchandise hereunder shall be provided by TRUSTEE unless, prior to PURCHASER/BENEFICIARYS death, PURCHASER/BENEFICIARY designates a different funeral establishment as TRUSTEE under this Agreement. In consideration of their mutual promises, and in accordance with Section 149.11 of the Minnesota Statutes as it may be amended from time to time, PURCHASER/BENEFICIARY and TRUSTEE agree as follows:

1. TRUSTEE. The following named funeral establishment shall serve as Trustee under this Agreement: Nelson Funeral Home_________________________________________________________ (Name of funeral establishment as it appears on its permit from the Minnesota State Commissioner of Health, hereinafter TRUSTEE) 2. Services and Merchandise. a) TRUSTEE will provide the following services (burial expenses): Funeral director/staff: $500.00, Transfer of remains: $100.00, Embalming: $800.00, Other preparation of the body: $300, Facility use for service: $200, Hearse for committal service: 100.00 _______________________ (These funds are irrevocable to the maximum extent allowed by law) b) TRUSTEE will provide the following merchandise (burial space items): Casket $3000.00, outer receptacle: $900.00, marker: $100.00, space $1000 _________ 3. Deposit with Trustee. 2.a) the amount to be deposited by PURCHASER/BENEFICIARY with TRUSTEE under this Agreement for services described in Item 2.a) is $ ____2000.00_______ 2.b) the amount to be deposited by PURCHASER/BENEFICIARY with TRUSTEE under this Agreement for Merchandise described in item 2.b is ___5000.00_________ c.) The total amount to be deposited under this agreement is (2.a & 2.b): $7000.00__________ It is PURCHASER/BENEFICIARYS intention that the amount to be held in trust is irrevocable up to an amount equivalent to the then-current allowable Supplemental Security Income (SSI) asset exclusions used for determining eligibility for public assistance.



(Purchaser/Beneficiary, Please Note: You may deposit an amount or amounts with TRUSTEE which exceeds the asset exclusion limitations allowable under Supplemental Security Income (SSI). However, only those amounts up to the SSI Asset exclusion limitation may be designated as irrevocable. Any amounts deposited which exceed SSI Asset exclusion limitation swill not be irrevocable and may be withdrawn by you at any item). 4. Financial Institution/Interest. TRUSTEE shall deposit the amount set forth in Items 3.c) above into a separate designated trust account with an insured financial institution as defined in Minnesota Statue 49.01, subd 2 ( hereinafter financial Institution) pursuant to Minn. Stat 149.12. Such account shall be an insured account which shall bear interest at the then current interest rate offered by Financial Institution on savings accounts of the size of PURCHASER/BENEFICIARYS deposit with TRUSTEE described in Item 3.c.) above. The interest on irrevocable trust funds is hereby declared:

Irrevocable Or (Purchaser/Beneficiary please check one of these boxes and initial here): X AD_______

Revocable 5. Account Names. The account to be opened by TRUSTEE with financial Institution as described in Item 4 above shall bear each and every of the following names: a) Purchaser and designated Beneficiary: ________________Aman Das___________________ b) Trustee funeral establishment: Nelson Funeral Home_________________________________________ c) Financial Institution: Wells Fargo___________________________________________________________ This Agreement benefits and binds the devisees, heirs, successors, assigns, and personal representatives(s) of Purchaser/beneficiary, Trustee and Financial Institution. Signed at Minneapolis___________, Minnesota this 9th____ day of September_____ of 2004_______ Purchaser: Aman Das_________________ TRUSTEE: Nelson Funeral Home________________ By: John Nelson_______________________ Funeral Director

Nelson Funeral Home 400 13th Ave. N.E. Minneapolis, MN 55418 612-386-3725

Irrevocable Funeral Trust Agreement For the benefit of ______Padma Das___________ (BENEFICIARY of Trust) PURCHASER/BENEFICIARY under this Agreement must be the Beneficiary of the Trust This Irrevocable Funeral Trust Agreement is made by and between the undersigned contract purchase and beneficiary of funeral services and/or merchandise (hereinafter PURCHASER/BENEFICIARY) and the funeral establishment as defined by and licensed pursuant to Minnesota Statute 149.08 and designated below as TRUSTEE. The purpose of this Irrevocable Funeral Trust Agreement is to set forth in advance certain arrangements regarding burial expenses and/or expenses for burial space items to be incurred on behalf of PURCHASER/BENEFICIARY. The services and merchandise hereunder shall be provided by TRUSTEE unless, prior to PURCHASER/BENEFICIARYS death, PURCHASER/BENEFICIARY designates a different funeral establishment as TRUSTEE under this Agreement. In consideration of their mutual promises, and in accordance with Section 149.11 of the Minnesota Statutes as it may be amended from time to time, PURCHASER/BENEFICIARY and TRUSTEE agree as follows:

1. TRUSTEE. The following named funeral establishment shall serve as Trustee under this Agreement: Nelson Funeral Home_________________________________________________________ (Name of funeral establishment as it appears on its permit from the Minnesota State Commissioner of Health, hereinafter TRUSTEE) 2. Services and Merchandise. a) TRUSTEE will provide the following services (burial expenses): __________________________________________________________________________________________ (These funds are irrevocable to the maximum extent allowed by law) b) TRUSTEE will provide the following merchandise: Casket: $3327.00 _________ 3. Deposit with Trustee. 2.a) the amount to be deposited by PURCHASER/BENEFICIARY with TRUSTEE under this Agreement for services described in Item 2.a) is 2.b) the amount to be deposited by PURCHASER/BENEFICIARY with TRUSTEE under this Agreement for Merchandise described in item 2.b is $3327.00____________________________________________________________________________ c.) The total amount to be deposited under this agreement is (2.a & 2.b): $3327.00__________ It is PURCHASER/BENEFICIARYS intention that the amount to be held in trust is irrevocable up to an amount equivalent to the then-current allowable Supplemental Security Income (SSI) asset exclusions used for determining eligibility for public assistance. (Purchaser/Beneficiary, Please Note: You may deposit an amount or amounts with TRUSTEE which exceeds the asset exclusion limitations allowable under Supplemental Security Income (SSI). However, only those amounts up to



the SSI Asset exclusion limitation may be designated as irrevocable. Any amounts deposited which exceed SSI Asset exclusion limitation swill not be irrevocable and may be withdrawn by you at any item). 4. Financial Institution/Interest. TRUSTEE shall deposit the amount set forth in Items 3.c) above into a separate designated trust account with an insured financial institution as defined in Minnesota Statue 49.01, subd 2 ( hereinafter financial Institution) pursuant to Minn. Stat 149.12. Such account shall be an insured account which shall bear interest at the then current interest rate offered by Financial Institution on savings accounts of the size of PURCHASER/BENEFICIARYS deposit with TRUSTEE described in Item 3.c.) above. The interest on irrevocable trust funds is hereby declared:

Irrevocable Or (Purchaser/Beneficiary please check one of these boxes and initial here): X PD______

Revocable 5. Account Names. The account to be opened by TRUSTEE with financial Institution as described in Item 4 above shall bear each and every of the following names: a) Purchaser and designated Beneficiary: ________________Padma Das___________________ b) Trustee funeral establishment: Nelson Funeral Home_________________________________________ c) Financial Institution: Wells Fargo___________________________________________________________ This Agreement benefits and binds the devisees, heirs, successors, assigns, and personal representatives(s) of Purchaser/beneficiary, Trustee and Financial Institution. Signed at Minneapolis___________, Minnesota this 9th____ day of September_____ of 2004_______ Purchaser: Padma Das______________ TRUSTEE: Nelson Funeral Home________________ By: John Nelson_______________________ Funeral Director

Ramsey County, MN

Property Information Search Result

Parcel Data for Taxes 2006

Property ID: 12-874-24-22-8579 Address: 1666 White Bear Avenue Municipality: St. Paul School District: 062 Construction year: 1922 Watershed: 5 Approx. Parcel Size: 40.00 X 128.00 Owner Name: Padma and Aman Das & Address: 1666 White Bear Avenue St. Paul, MN 55106

Most Current Sales Information Sale Date: July 1988 Sale Price: $50,900 Transaction Type: Other See Certificate of Real Estate Value

Value and Tax Summary for Taxes Payable 2006 Values Established by Assessor as of January 2, 2006

Estimated Market Value: $275,000 Limited Market Value: $275,000 Taxable Market Value: $275,000 Total Improvement Amount: Total Net Tax: $3,500.12 Total Special Assessments: Solid Waste Fee: $ 41.86 Total Tax: $1,541.98 Copyright 2006 Ramsey County, Minnesota www.Ramsey.us


Wells Fargo 846 Johnson Parkway St. Paul, MN 55106 (800) 869-3557

Padma and Aman Das 1666 White Bear Avenue St. Paul, MN 55106

8/15/2006 Dear Mr. and Mrs. Das, Per your written request, your mortgage information on July 12, 2006, is listed below. Mortagage Number: 8800020001-MT Activity Summary: Balance on 07/12/2006 $105,594.00

Please contact me if you have questions. Joe E. Banker Joe E. Banker Branch Vice President


https://www.wellsfargo.com/

Barron County, WI

Property Information Search Result

Parcel Data for Taxes 2006

Property ID: 12-120-24-19-5478 Address: 1622 Horseshoe Court Municipality: Turtle Lake School District: 854 Construction year: 1975 Watershed: 3 Approx. Parcel Size: 40.00 X 128.00 Owner Name: Padma and Aman Das & Address: 1622 Horseshoe Court Turtle Lake, WI

Most Current Sales Information Sale Date: November 1992 Sale Price: $30,900 Transaction Type: Other See Certificate of Real Estate Value

Value and Tax Summary for Taxes Payable 2006 Values Established by Assessor as of January 2, 2006

Estimated Market Value: $98,300 Limited Market Value: $98,300 Taxable Market Value: $98,300 Total Improvement Amount: Total Net Tax: $ 900.12 Total Special Assessments: Solid Waste Fee: $ 21.86 Total Tax: $ 921.98 Copyright 2006 Barron County, Wisconsin


Body Style > Make > Year > Model & Trim > Mileage & Options > Value Report 2004 Buick LeSabre-V6 Sedan 4D Custom

August 31, 2006

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PRICING RoughTrade-In

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Clean Trade-In

CleanRetail

Base Price $78,475 $8,750 $9,525 $10,425Options

TOTAL PRICE $7,475 $8,750 $9,525 $10,425*

* This Retail price is based on a clean vehicle history report. Don't make a $10,425 mistake. Get a Free VIN Check today.


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> Make > Year > Model & Trim > Mileage & Options > Value ReportBody Style 2003 Hyundai Sonata-V6 Sedan 4D

August 31, 2006

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PRICING RoughTrade-In

AverageTrade-In

Clean Trade-In

CleanRetail

Base Price $6,825 $7,225 $8,275 $5,650Options

Power Windows N/A N/A N/A N/A

Power Door Locks N/A N/A N/A N/A

Cruise Control N/A N/A N/A N/A

TOTAL PRICE $6,825 $7,225 $8,275 $9,650*

* This Retail price is based on a clean vehicle history report. Don't make a $9,650 mistake. Get a Free VIN Check today.


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800 E. 28th Street Minneapolis, MN 55407

Padma Das 1666 White Bear Avenue St. Paul, MN 55106 August 15, 2006 Dear Ms. Das, This letter is in response to your inquiry received July 31, 2006. You were admitted to Abbott Northwestern Hospital on July 12, 2006, and discharged on August 12, 2006. Your medical records indicate you received long-term care services throughout your hospital stay. Please contact me if you have further questions. Sincerely, Maria Rivera Admitting Supervisor

St. Anne Care Center 420 Marshall Street St. Paul, MN 55102

Padma Das 1666 White Bear Avenue St. Paul, MN 55106 August 27, 2006 Dear Ms. Das, You were admitted to St. Anne Care Center on August 12, 2006, and were discharged on August 27, 2006. Please contact me if you have further questions. Sincerely, Cori Hart Vice President of Administration

http://www.abbottnorthwestern.com/ahs/anw.nsf/

09 Padma and Aman Vehicle NADA Info.pdf2004 Buick LeSabre-V6 Sedan 4D CustomPRICING

2003 Hyundai Sonata-V6 Sedan 4DPRICING

clear_button: info: name: first: Pamami: Plast: Das

dob: 04/01/CY-76ssn: 770-11-XXXXhome_phone: (651) 555-8901address: county: Ramsey street: 1666 White Bear Avenuecity: St. Paulstate: MNzip: 55106

spouse: name: first: Amanmi: Dlast: Das

dob: 02/24/CY-78ssn: 700-85-XXXXhome_phone: (651) 555-8901address: county: Ramsey street: 1666 White Bear Avenuecity: St. Paulstate: MNzip: 55106

race-asian: race-black: race-american_indian: race-pacific: race-white: Yeshispanic: No

gender: Femalerace-asian: race-black: race-american_indian: race-pacific: race-white: Yeshispanic: No

q1-checkbox: Noq1: hospital: A: B:

3340date received: 8/30/063340case number: 3340worker number: 3340updatedlast: Updated 4/12/11q2-checkbox: Yesq2: C: 7/12/2006

q3-checkbox: Noq3: D:

q4-checkbox: Noq4: hospital: E: F:

q5: G: 7/12/2006

q6-checkbox: Noq6: county-state:

1: cash: 0.00

2-checkbox: Yes2: name: 0: Padma Das1: Aman Das2: Aman and Padma Das3: Aman Das4: 5: 6:

account: 0: Savings1: Savings2: Checking3: CD4: 5: 6:

bank: 0: Wells Fargo - St. Paul, MN1: Wells Fargo - St. Paul, MN2: Wells Fargo - St. Paul, MN3: Wells Fargo - St. Paul, MN4: 5: 6:

account_number: 0: 8800020001-SV1: 45869521-SV2: 880220022-CK3: 4587965-CD4: 5: 6:

3-checkbox: Yes3: name: 0: Aman Das1: 2: 3: 4: 5:

investment: 0: Pension Fund1: 2: 3: 4: 5:

bank: 0: Big Business Enterprise1: 2: 3: 4: 5:

account_number: 0: ?1: 2: 3: 4: 5:

4-checkbox: Yes4: name: 0: Aman and Padma Das1: Aman and Padma Das2:

property: 0: Home1: Lake Home2:

address: 0: 1666 White Bear Ave., St. Paul, MN1: 1622 N Horseshoe Ct, Turtle Lake, WI2:

live: 0: Yes1: No2:

3340assetdate: 7/12/20065-checkbox: No5: name: 0: 1:

asset: 0: 1:

6-checkbox: Yes6: name: 0: Aman Das1: Padma Das 2: 3:

vehicle: 0: Car1: Car2: 3:

year-make-model: 0: 2004/Buick/LeSabre1: 2003/Hyundai/Sonata2: 3:

7-checkbox: Yes7: name: 0: Padma Das1:

type: 0: Lincoln National Life Insurance Co. - Annuity1:

8-checkbox: No8: name: 0: 1: 2: 3:

policy_number: 0: 1: 2: 3:

insurance: 0: 1: 2: 3:

9-checkbox: Yes9: name: 0: Padma Das1: Aman Das2:

burial: 0: Irrevocable Burial Contract1: Irrevocable Burial Contract2:

company: 0: Nelson Funeral Home/Wells Fargo Bank1: Nelson Funeral Home/Wells Fargo Bank2:

10-checkbox: No10: name: 0: 1: 2: 3:

asset: 0: 1: 2: 3:

operation: operation_reason:

11-checkbox: No11: name: 0: 1: 2: 3: 4: 5: 6: 7:

asset: 0: 1: 2: 3: 4: 5: 6: 7:

12-checkbox: Nosignature: relationship: address: phone:

3340signature: Padma Das3340spousesignature: Aman Das3340date2: 08/30/063340date3: 3340arep: