Special Assistance SA3200f4

Figure 4 - AGREEMENT TO SELL PROPERTY

Applicant/Recipient’s Name		SSN
Description of Each Resource To Be Excluded (Include Address If Real Property)	Name of Owners			Percentage Ownership		Estimated CMV	Amount Owed on Resource If Any	Estimated Net Proceeds From Sale
CONDITIONS OF AGREEMENT: I understand that my resources exceed the amount that I may have to qualify for Special Assistance. I hereby request that I receive Special Assistance benefits while I make reasonable efforts to sell the property listed above at its current market value. Once the Department of Social Services notifies me that this agreement has been approved, I agree to take all necessary steps to sell the resources, and to continue to do so until the resources are sold. I agree to sell the resources for the highest price I can get. I agree to sell the personal property listed above within 3 months of being notified that the agreement is acceptable and the real property listed above within 9 months of being notified that the agreement is acceptable. I agree to notify the Department of Social Services within 5 days of any sale. I further agree to immediately repay all benefits that would not have been received had I sold the resources on the day I applied for benefits. I further understand that if I fail to comply with the terms of this agreement, I will be required to make an immediate refund of all payments received.
Applicant/Recipient’s Signature (Or Representative)			Address/Phone						Date
Caseworker’s Signature			Address/Phone						Date
Witness Signature			Address/Phone						Date

SA-3200 – Figure 4

Eff. 12/01/02