Get Wv Dhhs Dfa-uh-5 2012-2025

The WV DHHS DFA-UH-5 is an application form for the undue hardship waiver designed to assist individuals facing financial challenges in accessing necessary care. This guide will provide you with clear, step-by-step instructions on how to complete the form effectively online.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your personal information in the Applicant Information section, including your name, address, date of birth, county of residence, and telephone number.
3. If someone else is making the request on your behalf, include their name, address, and relationship to you in the designated fields.
4. Indicate whether the residence is a long-term-care facility and, if applicable, provide the signature of the individual granting permission for long-term-care facility staff to apply.
5. Select the basis for your claim of undue hardship by checking one of the following options: excessive home equity, transfer to a non-permissible trust, or transfer of asset penalty.
6. If your request is related to a transfer of resources, indicate whether you or your representative are making a good faith effort to recover fair market value for the transferred assets by selecting 'yes' or 'no.' Attach any necessary documentation to support your explanation.
7. Answer whether you have other sources of income or assets that can provide for your necessities, and describe any additional factors that should be considered regarding your claim.
8. Affirm that the information provided is true by signing and dating the form at the bottom.
9. Finally, complete the submission process by sending the completed form along with any supporting documents to the specified WV DHHR County Office within the given time frame.

Complete your application for the undue hardship waiver online to ensure you receive the assistance you need.