HUD 90101 Certification for Qualified Long-Term Care Insurance Exp

Certification of Long-Term Care Insurance

U.S. Department of Housing and Urban Development Office of Housing Federal Housing Commissioner

OMB Approval No. 2502–0204 (Exp. xx/xx/xxxx)

Public Reporting Burden. The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, 451 7th St SW, Room 8210, Washington, DC 20410–5000. Do not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid OMB control number. HUD collects this information to determine whether an applicant’s or participant’s unreimbursed expenses for long-term care insurance must be deducted from the family’s income according to 24 C.F.R. § 5.611(a)(3)(i), which establishes a threshold of 10 percent of annual income for the mandatory deduction of unreimbursed health and medical care expenses of any elderly or disabled family. HUD uses this information to assist in managing certain HUD properties, to protect the Government’s financial interest, and to verify the accuracy of the information furnished. This information is considered non-sensitive and does not require special protection.

Exhibit 5-4: Certification for Qualified Long-Term Care Insurance Expenses

I certify that the long-term care insurance policy for which I pay premiums, (insert policy provider name) ____________________________________, policy number ______________ meets the following conditions.

1. It is guaranteed renewable;

2. It does not provide a cash surrender value which can be paid, assigned, pledged, or borrowed;

3. It provides that refunds (other than refunds on the death of the insured or complete surrender or cancellation of the contract) and dividends under the contract may be used only to reduce future premiums or increase future benefits; and,

4. It does not pay or reimburse expenses incurred for services or items that would be reimbursed under Medicare (except where Medicare is a secondary payer or the contract makes per diem or other periodic payments without regard to expenses).

Name (print)

Name (sign)

Unit Number

HUD form-90101