Annuity Designation for MA-LTC Applicants (DHS-5036)

Follow these instructions for the DHS-5036 to request annuity information from a Medical Assistance (MA) long-term care (LTC) applicant or from the applicant’s spouse.

1. Enter today’s date, the recipient’s address and your contact information

At the top of the form, enter today’s date, the recipient’s name and address and all the fields in the box found in the upper right corner.

2. Add your telephone number to the language block

Add your telephone number to the blank field at the top of the language block that appears at the end of the form.

3. Send the form to the recipient