Access NY Supplement A
community or life care community? If yes, send copy of agreement. Yes No Did you and/or your spouse file u.S. income tax returns in the last four years? Yes No If yes, send copies of these returns. DOH - 4495A 2/10 (page 5 of 6) NYS DOH G. Applicant Living in a Long-Term Care Facility/Nursing Home Name of Facility Date Admitted
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