Sample data. This is the unedited report Look-back packet builder produced on its bundled sample files, which describe a fictional business, run the same way a subscriber's upload is run (as of 2026-10-01). No AI model and no person touched it. Your own results depend on the exports you upload.
The full download also contains: packet/00_cover_sheet.html, packet/01_coverage.csv, packet/02_monthly_summary.csv, packet/03_items_to_explain.csv, packet/04_large_deposits.csv, packet/05_internal_transfers.csv, packet/06_all_transactions.csv, packet/07_document_checklist.md, report.html.
Medicaid look-back packet
Application date Oct 1, 2026. Large-amount threshold $1,000.00. The packet itself is in the packet/ folder; start with 00_cover_sheet.html.
- Look-back window Oct 1, 2021 through Sep 30, 2026 (60 months): 3 accounts, 721 transactions.
- Get statements (or confirm no activity) for 33 account-months with no transactions, in 3 gaps.
- Transfers mention account ...9876 (1 transaction), which is not in the upload: get its statements or note whose account it is.
- Explain 22 items totaling $61,565.00: fill in 03_items_to_explain.csv.
- Show the source of 59 large deposits totaling $118,344.00 (04_large_deposits.csv); 57 of them repeat month to month, like Social Security or a pension.
Accounts covered
| Account | Transactions | First | Last | Months with transactions | Months with none | Deposits | Withdrawals |
|---|---|---|---|---|---|---|---|
| BofA Savings ...5678 | 60 | 2022-01-28 | 2026-09-28 | 57 of 60 | 3 | $3,594.86 | $3,500.00 |
| Chase Checking ...1234 | 593 | 2021-10-01 | 2026-09-25 | 57 of 60 | 3 | $159,580.82 | $169,029.57 |
| Riverside CU Share Draft ...7788 | 68 | 2021-10-15 | 2024-06-27 | 33 of 60 | 27 | $13.44 | $11,405.92 |
Months with no transactions
A month with no activity looks the same as a missing statement. For each gap, either get the statement or note that the account had no activity (or was not open).
| Account | From | To | Months | What to do |
|---|---|---|---|---|
| BofA Savings ...5678 | 2021-10 | 2021-12 | 3 | BofA Savings ...5678 has no transactions for Oct 2021 through Dec 2021 (3 months): confirm there was no activity, or get those statements. If the account was opened during this time, note the opening date. |
| Chase Checking ...1234 | 2023-04 | 2023-06 | 3 | Chase Checking ...1234 has no transactions for Apr 2023 through Jun 2023 (3 months): confirm there was no activity, or get those statements. |
| Riverside CU Share Draft ...7788 | 2024-07 | 2026-09 | 27 | Riverside CU Share Draft ...7788 has no transactions for Jul 2024 through Sep 2026 (27 months): confirm there was no activity, or get those statements. If the account was closed, get the closing statement showing where the balance went. |
Items a caseworker will ask about
22 withdrawals totaling $61,565.00. Each row in 03_items_to_explain.csv has blank Explanation and Supporting document columns for staff or family to fill in. Each item is counted once, under its first matching category.
| Category | Items | Total |
|---|---|---|
| Transfer to a person or outside account | 3 | $6,545.00 |
| Check | 2 | $6,250.00 |
| Cash withdrawal | 8 | $4,120.00 |
| Large withdrawal or payment | 8 | $44,150.00 |
| Round-number withdrawal | 1 | $500.00 |
All items:
| Ref | Date | Account | Description | Amount | Category | Why it is listed |
|---|---|---|---|---|---|---|
| T00195 | 2022-11-02 | Chase Checking ...1234 | VANGUARD BUY INVESTMENT | $10,000.00 | Large withdrawal or payment | Withdrawal or payment at or above $1,000.00; Round-number amount (caseworkers often ask whether this was a gift) |
| T00572 | 2026-02-10 | Chase Checking ...1234 | ACH DEBIT HILLSIDE FUNERAL HOME PRENEED | $8,950.00 | Large withdrawal or payment | Withdrawal or payment at or above $1,000.00 |
| T00293 | 2023-11-20 | Chase Checking ...1234 | CHECK 1043 | $5,000.00 | Check | Check at or above $1,000.00: who was it written to and why (the bank can provide a copy of the cleared check); Withdrawal or payment at or above $1,000.00; Round-number amount (caseworkers often ask whether this was a gift) |
| T00590 | 2026-04-02 | Chase Checking ...1234 | ACH DEBIT SUNRISE ASSISTED LIVING | $4,200.00 | Large withdrawal or payment | Withdrawal or payment at or above $1,000.00 |
| T00601 | 2026-05-02 | Chase Checking ...1234 | ACH DEBIT SUNRISE ASSISTED LIVING | $4,200.00 | Large withdrawal or payment | Withdrawal or payment at or above $1,000.00 |
| T00612 | 2026-06-02 | Chase Checking ...1234 | ACH DEBIT SUNRISE ASSISTED LIVING | $4,200.00 | Large withdrawal or payment | Withdrawal or payment at or above $1,000.00 |
| T00623 | 2026-07-02 | Chase Checking ...1234 | ACH DEBIT SUNRISE ASSISTED LIVING | $4,200.00 | Large withdrawal or payment | Withdrawal or payment at or above $1,000.00 |
| T00634 | 2026-08-02 | Chase Checking ...1234 | ACH DEBIT SUNRISE ASSISTED LIVING | $4,200.00 | Large withdrawal or payment | Withdrawal or payment at or above $1,000.00 |
| T00645 | 2026-09-02 | Chase Checking ...1234 | ACH DEBIT SUNRISE ASSISTED LIVING | $4,200.00 | Large withdrawal or payment | Withdrawal or payment at or above $1,000.00 |
| T00486 | 2025-06-02 | Chase Checking ...1234 | Online Transfer to CHK ...9876 transaction#: ...8457 | $4,000.00 | Transfer to a person or outside account | Transfer to account ...9876, which is not in this upload: get that account's statements or say whose account it is; Withdrawal or payment at or above $1,000.00; Round-number amount (caseworkers often ask whether this was a gift) |
| T00374 | 2024-07-12 | Chase Checking ...1234 | Zelle payment to Emily Carter JPM99b7k1x2c | $2,500.00 | Transfer to a person or outside account | Payment-app or person-to-person transfer: say who received it and why; Withdrawal or payment at or above $1,000.00; Round-number amount (caseworkers often ask whether this was a gift) |
| T00015 | 2023-02-07 | BofA Savings ...5678 | Counter Withdrawal | $2,000.00 | Cash withdrawal | Cash withdrawal at or above $500.00: what was the cash used for; Part of $2,060.00 in cash withdrawn in Feb 2023 (2 withdrawals); Withdrawal or payment at or above $1,000.00; Round-number amount (caseworkers often ask whether this was a gift) |
| T00668 | 2022-05-09 | Riverside CU Share Draft ...7788 | CHECK 2051 | $1,250.00 | Check | Check at or above $1,000.00: who was it written to and why (the bank can provide a copy of the cleared check); Withdrawal or payment at or above $1,000.00 |
| T00166 | 2022-08-05 | Chase Checking ...1234 | WITHDRAWAL 08/05 BRANCH 0412 | $800.00 | Cash withdrawal | Cash withdrawal at or above $500.00: what was the cash used for |
| T00552 | 2025-12-15 | Chase Checking ...1234 | BILL PAY MICHAEL CARTER | $500.00 | Round-number withdrawal | Round-number amount (caseworkers often ask whether this was a gift) |
| T00442 | 2025-02-03 | Chase Checking ...1234 | ATM WITHDRAWAL 007731 OAK AVE | $300.00 | Cash withdrawal | Part of $1,260.00 in cash withdrawn in Feb 2025 (5 withdrawals) |
| T00445 | 2025-02-10 | Chase Checking ...1234 | ATM WITHDRAWAL 007790 OAK AVE | $300.00 | Cash withdrawal | Part of $1,260.00 in cash withdrawn in Feb 2025 (5 withdrawals) |
| T00448 | 2025-02-17 | Chase Checking ...1234 | ATM WITHDRAWAL 007812 OAK AVE | $300.00 | Cash withdrawal | Part of $1,260.00 in cash withdrawn in Feb 2025 (5 withdrawals) |
| T00451 | 2025-02-24 | Chase Checking ...1234 | ATM WITHDRAWAL 007856 OAK AVE | $300.00 | Cash withdrawal | Part of $1,260.00 in cash withdrawn in Feb 2025 (5 withdrawals) |
| T00232 | 2023-02-20 | Chase Checking ...1234 | ATM WITHDRAWAL 004512 MAIN ST | $60.00 | Cash withdrawal | Part of $2,060.00 in cash withdrawn in Feb 2023 (2 withdrawals) |
| T00450 | 2025-02-20 | Chase Checking ...1234 | ATM WITHDRAWAL 004512 MAIN ST | $60.00 | Cash withdrawal | Part of $1,260.00 in cash withdrawn in Feb 2025 (5 withdrawals) |
| T00521 | 2025-09-14 | Chase Checking ...1234 | VENMO PAYMENT ...6789 JAKE CARTER | $45.00 | Transfer to a person or outside account | Payment-app or person-to-person transfer: say who received it and why |
Large deposits
59 deposits at or above $1,000.00, totaling $118,344.00 (Deposit: 59). 57 repeat month to month; one award letter or pay statement usually covers those.
Largest one-off deposits:
| Ref | Date | Account | Description | Amount | Category |
|---|---|---|---|---|---|
| T00334 | 2024-03-18 | Chase Checking ...1234 | REMOTE ONLINE DEPOSIT #1 | $12,000.00 | Deposit |
| T00472 | 2025-04-20 | Chase Checking ...1234 | IRS TREAS 310 TAX REF | $1,350.00 | Deposit |
Transfers between the uploaded accounts
3 transfers matched: same amount out of one uploaded account and into another within 3 days. These are not listed as items to explain.
| Date out | From | To | Amount | Days apart |
|---|---|---|---|---|
| 2022-03-10 | Chase Checking ...1234 | BofA Savings ...5678 | $3,000.00 | 1 |
| 2024-01-05 | BofA Savings ...5678 | Chase Checking ...1234 | $1,500.00 | 3 |
| 2024-06-27 | Riverside CU Share Draft ...7788 | Chase Checking ...1234 | $4,830.02 | 1 |
Document checklist
| Document | Found in upload |
|---|---|
| Bank statements for every account (checking, savings, money market, CDs) for the full look-back period, every page | Partly: 3 accounts uploaded; 33 account-months have no transactions (see 01_coverage.csv); transfers mention ...9876, not uploaded |
| Statements for accounts closed during the look-back period, including the final statement showing where the balance went | Possibly: Riverside CU Share Draft ...7788 has no transactions after Jun 2024 |
| Brokerage, retirement (IRA, 401(k)), annuity and other investment statements for the full period | Not in upload, but 1 transaction may relate (see examples below) |
| Life insurance policies, including any cash value statement | Not in upload, but 57 transactions may relate (see examples below) |
| Real estate deeds and any documents for property sold or transferred | No: this tool reads bank statements only; no related transactions spotted |
| Trust documents (the trust agreement and any amendments) | No: this tool reads bank statements only; no related transactions spotted |
| Records explaining gifts, transfers and large withdrawals or deposits (receipts, letters, copies of checks) | Started: 03_items_to_explain.csv and 04_large_deposits.csv list 81 transactions; the Explanation and Supporting document columns still need filling in |
| Prepaid burial or funeral contracts (irrevocable or revocable) | Not in upload, but 1 transaction may relate (see examples below) |
Details and related transactions are in packet/07_document_checklist.md.
What is in the packet
| File | What it is |
|---|---|
| packet/00_cover_sheet.html | This cover sheet: applicant, look-back window, accounts, counts. |
| packet/01_coverage.csv | Every account and every month in the window, with months that have no transactions marked. |
| packet/02_monthly_summary.csv | Deposits, withdrawals and opening/closing balances for each account and month. |
| packet/03_items_to_explain.csv | Withdrawals, checks, cash and transfers a caseworker is likely to ask about, with blank Explanation and Supporting document columns to fill in. |
| packet/04_large_deposits.csv | Large deposits, with blank columns for the source of the money and its proof. |
| packet/05_internal_transfers.csv | Money moved between the uploaded accounts (matched, not counted as items). |
| packet/06_all_transactions.csv | Every transaction in the window, sorted by account then date. |
| packet/07_document_checklist.md | The other documents the application usually needs, with what we could see. |
What we read
| File | Read as | Account | Rows | Used | Outside window | Duplicates | Skipped |
|---|---|---|---|---|---|---|---|
| statements/bofa-savings-5678.csv | comma-separated, header on line 7 | BofA Savings ...5678 | 61 | 60 | 0 | 0 | 1 |
| statements/chase-checking-1234-2026-07.csv | comma-separated, header on line 1 | Chase Checking ...1234 | 11 | 11 | 0 | 0 | 0 |
| statements/chase-checking-1234.csv | comma-separated, header on line 1 | Chase Checking ...1234 | 616 | 582 | 23 | 11 | 0 |
| statements/riverside-cu.csv | comma-separated, header on line 1 | Riverside CU Share Draft ...7788 | 76 | 68 | 8 | 0 | 0 |
Rows skipped: 1 no amount (balance, total or summary line).
Left out 29 transactions dated before Oct 1, 2021 and 2 transactions dated on or after the application date.
Removed 11 duplicate rows that appeared in more than one file.
This packet organizes bank records for a Medicaid application. It is not legal advice and not an eligibility decision. Look-back length and rules vary by state: most states look back 60 months, but some use a different period, so check your state's current rule. Whether a transfer causes a penalty is decided by the Medicaid agency, not by this tool.
Limits: we read only the bank CSV files uploaded. A month with no transactions looks the same as a missing statement, so each one needs confirming. Categories come from transaction descriptions and can miss or over-flag items; a person should review every row before the packet is submitted.