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Ate Form Remailed Date Form Returned Appointment Date DECLARATION OF RESOURCES/DECLARACI N DE RECURSOS Complete all items. If the answer is None, write None in the space provided or check No. Llene todos los lugares. Si la respuesta es Nada , escriba Nada en el lugar indicado, o marque No. SECTION 1 APPLICANT/RECIPIENT AND SPOUSE/SECCION 1 SOLICITANTE/CLIENTE Y ESPOSA(O) Name (as it appears on Medicare card) Nombre (como aparece en la tarjeta de Med.

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