Form H1245, Statement of Intent to Return to Home

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Effective Date: 9/1997


Updated: 8/2001


  • To serve as primary evidence of the client's intent to return home so that the home may continue to be excluded as a resource.
  • To determine the current status of the client's home (for example, rented/leased, occupied but no money received, producing other income, vacant, listed for sale).
  • To notify the client that the home may become a countable resource if it ceases to be his principal place of residence.
  • To notify the client that transferring the home could affect his benefits.
  • To notify the client that sale of the home could affect his benefits when the proceeds are received.


When to Prepare

The client, his responsible party, or his physician completes Form H1245 whenever the client plans to return home. Once Form H1245 is completed, it should not be necessary to complete it again since a question about intent to return is included on Form H1200-A, Medical Assistance Only (MAO) Recertification.

Number of Copies

Complete an original and one copy of Form H1245.


The original of Form H1245 is filed in the case record.

The copy is given to the client or his responsible party.

Form Retention

Form H1245 is retained permanently in the case record.