What is a Statement of Intent to Return Home Form?

Definition & Meaning

A Statement of Intent to Return Home is a legal document that serves as a declaration by an individual indicating their intention to return to their primary residence after a temporary absence. This absence may occur due to various reasons, such as receiving long-term care in a nursing home or rehabilitation facility. The primary purpose of this statement is to ensure that the individual’s home is not counted as an asset when applying for Medicaid long-term care benefits. By affirming the intent to return, the individual can protect their home from being classified as a countable asset, which is crucial for qualifying for necessary financial assistance.

How to Use the Statement of Intent

The Statement of Intent to Return Home is utilized primarily during the Medicaid application process. When an individual applies for Medicaid benefits, they must demonstrate that their home is exempt from asset limits. To use the statement effectively:

• Complete the Form: Fill out the statement accurately, including personal details and the address of the primary residence.
• Sign and Date: Ensure that the document is signed and dated by the individual or their authorized representative.
• Submit with Application: Include the statement with the Medicaid application to validate the intent to return home.

How to Obtain the Statement of Intent

Obtaining a Statement of Intent to Return Home typically involves a straightforward process. Individuals can acquire the form through various means:

• State Medicaid Office: Many states provide the form directly through their Medicaid offices, either online or in person.
• Legal Assistance: Consulting with an attorney specializing in elder law can also help in obtaining and understanding the form.
• Healthcare Providers: Some healthcare facilities may have copies of the statement available for residents receiving long-term care.

How to Fill Out the Statement of Intent

Filling out the Statement of Intent to Return Home requires careful attention to detail. Here are the steps to ensure accuracy:

• Personal Information: Provide your full name, address, and contact information.
• Details of Absence: Clearly state the reason for your temporary absence from the home, such as medical treatment.
• Affirmation of Intent: Include a clear statement affirming your intention to return home once your health allows.
• Signature: Sign the document, and if applicable, have an authorized representative sign as well.

Key Elements of the Statement

Several key elements must be included in the Statement of Intent to Return Home to ensure its validity:

• Declaration of Intent: A clear statement that expresses the individual’s intention to return to their primary residence.
• Primary Residence Confirmation: A declaration that the home is still considered the primary residence of the individual.
• Temporary Absence Explanation: A brief explanation of the circumstances leading to the temporary absence.
• Timeframe: An indication of the expected duration of absence, which can vary based on individual health circumstances.

State-Specific Rules for the Statement

Each state in the U.S. may have its own regulations regarding the Statement of Intent to Return Home. It is essential to be aware of these differences:

• Form Variations: Some states may have specific forms that differ in language or requirements.
• Documentation Requirements: Certain states might require additional documentation, such as a physician’s note, to validate the intent to return.
• Time Limits: The duration for which the home can remain exempt may vary, typically ranging from six months to one year.

Examples of Using the Statement

Understanding practical scenarios can clarify the use of the Statement of Intent to Return Home:

• Example One: An elderly individual enters a nursing home for rehabilitation after surgery. They fill out the statement to ensure their home remains exempt while they recover.
• Example Two: A person with chronic health issues temporarily moves into assisted living. They submit the statement to protect their home from being counted as an asset during their treatment period.

Important Considerations

When preparing to use the Statement of Intent to Return Home, several important considerations should be kept in mind:

• Proof of Intent: Be prepared to provide additional evidence of your intent to return, such as a discharge plan from a healthcare provider.
• Authorized Representatives: Understand who can act on your behalf if you are unable to complete the statement yourself.
• Consult Legal Advice: It may be beneficial to consult with a legal professional to ensure compliance with state-specific requirements.