Notice of Obligation to Issuer of an Annuity (DHS-5037)

Follow these instructions for the DHS-5037 to ensure DHS is designated as a preferred remainder beneficiary of an annuity when a person is applying for Medical Assistance (MA) long-term care (LTC) services.

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

At the top of the form, enter today’s date, the annuity issuer’s name and address and all the fields in the box found in the upper right corner. Complete all fields, as some of your entries will autofill other fields throughout the rest of the document.

2. Enter the annuity issuer’s information

Enter the annuity company name, annuity contract number, annuity company address and name(s) of the annuity owner(s) in the fields provided.

3. Attach a copy of the completed DHS-5036

4. 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.

5. Send both the DHS-5036 and DHS-5037 to the annuity issuer