Get Ca Dhcs 6195 2020-2025

Filling out the CA DHCS 6195 form is an important step in applying for a hardship waiver regarding the estate claim. This guide will walk you through each section of the form, providing clear and supportive instructions, ensuring you understand what information is needed.

Follow the steps to complete the form accurately and efficiently.

1. Press the 'Get Form' button to access the form and open it in the editing interface.
2. Begin with Section A, where you will provide the decedent's estate information. Fill in the decedent’s name and DHCS account number, and indicate whether there was a predeceased spouse or registered domestic partner who was also on Medi-Cal.
3. If applicable, provide the name and account number of the predeceased spouse or partner. Additionally, answer questions regarding whether the estate property is held in a trust and if a will exists.
4. Continue completing Section A by detailing the estate property, including real property, mobile homes, and any other assets in the decedent's name at the time of death. Attach any necessary documents such as deeds, mortgage statements, and appraisals.
5. You will also need to list any estate expenses incurred after the decedent’s death.
6. Move on to Section B, where you will enter your personal information as the applicant. Provide your full name, Social Security number, address, date of birth, and relationship to the decedent.
7. In Section C, check all applicable hardship waiver criteria that apply to your situation. Be sure to review the documentation required for each criterion and prepare to submit it along with the application.
8. Complete additional sections as required by the criteria you selected.
9. If necessary, fill out Sections D, E, and F, which pertain to your monthly income, monthly expenses, and value of assets, according to the previously selected criteria in Section C.
10. Attach required documentation such as tax statements, pay stubs, or bank statements.
11. Finally, in Section G, sign the certification, declaring that the information provided is true and correct to the best of your knowledge. Ensure that your contact information is included.
12. Review the completed form for accuracy, then save your changes. You can download, print, or share the form as needed.

Get started with your hardship waiver application today by filling out the CA DHCS 6195 form online.