All LTC applicants are required to complete Additional Financial Information for Long Term Care Applicants (HFS 3654). This form is used to obtain additional financial information and assess financial management.
At a minimum, form HFS 3654 must be signed. By doing so, consent is given to any investigation made by the Department to verify information on the form. Signing HFS 3654 is a condition of eligibility. If the applicant or representative refuses to sign HFS 3654, deny the application. Since the investigation process may be delayed otherwise, encourage applicants and representatives to complete HFS 3654 in full. However, FCRC staff are not required to ensure that HFS 3654 is completed in its entirety.