DHS-20, Verification of Assets
Name (Type or Print) Social Security Number THIS SECTION IS TO BE COMPLETED BY FINANCIAL INSTITUTION. NOTE: Please Report on Closed. Accounts if Closed Within Past . 36 Months Savings/Share. Account Certificate of Deposit Checking/Draft Account Long-Term Care Patient Trust Fund Prepaid Burial Account Other (Explain) 1. Account Number(s): 2. ................
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