Get Estate Recovery Program (erp) Disclosure

Filling out the Estate Recovery Program Disclosure is essential for those seeking benefits from Wisconsin Medicaid. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete the ERP Disclosure form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. In Section I, provide the county information by entering the date completed, agency name, worker's name, and the worker's telephone number.
3. Move to Section II, and fill in the applicant information. Enter the name of the applicant including last name, first name, and middle initial, along with their birthdate and Social Security Number. If the applicant has a spouse, indicate their name and address as necessary.
4. Proceed to Section III to input the spouse's information, including their name, birthdate, and Social Security Number. Clarify if the spouse is also an applicant by selecting 'Yes' or 'No'.
5. In Section IV, assess if you have any children who are blind, disabled, or under age 21. If yes, provide their detailed information including names, birthdates, addresses, and a brief explanation of their disabilities.
6. Next, in Section V, document asset information. Clearly indicate the dollar value for each category of property for the applicant, spouse, or jointly held assets. Attach a copy of the property tax bill for properties when required.
7. In Section VI, if applicable, indicate whether you are a guardian or hold power of attorney. Provide the guardian's or power of attorney's name, telephone number, and address.
8. Finally, in Section VII, ensure the signature field is filled by the applicant, guardian, or power of attorney. Enter the date signed and any additional comments where necessary. Review all entries for accuracy.
9. After completing the form, you can save any changes, download a copy, print it for your records, or share the form as needed.

Start completing your ERP Disclosure online today.