ASSET QUESTIONNAIRE FOR LONG TERM CARE PLANNING

Transcription

1 310 SE 8th Street, Ocala, Florida Post Office Box 1538, Ocala, Florida Ph: (352) Fax: (352) ASSET QUESTIONNAIRE FOR LONG TERM CARE PLANNING Throughout this Questionnaire, please use the back of each page to write additional information Date: Referred by: PERSONAL DATA of Person Who Will Receive Long Term Care Benefits: "Applicant" Name: Home Address: Telephone: Address: PERSONAL DATA of the Spouse: Spouse Name: Home Address: How long at this Address: Telephone: Telephone (cell): Address: Facility Name, Address & Telephone: Birth Date: Social Security No.: (Bring Social Security AND Medicare Card to Appointment) Social Services Person: Date of Admission to Hospital: Date of Admission to Facility: Dates of Medicare coverage: Birth Date: Place of Birth: Social Security Number: Community Spouse resides in: ( ) Rental home/apartment ( ) Own Home ( ) Nursing Home/Care Facility Name of Facility: (Bring Social Security AND Medicare Card and any other Insurance Card, Birth Certificate and Drivers License to Appointment)

2 FAMILY MEMBERS AND OTHERS INTERESTED IN APPLICANT'S WELFARE NAME: Date of Birth: NAME: Date of Birth: NAME: Date of Birth: NAME: Date of Birth: IMPORTANT Are any of your children on Social Security Disability?: Name of Child on Social Security Disability: DOES APPLICANT HAVE ANY OF THE FOLLOWING DOCUMENTS? LAST WILL AND TESTAMENT REVOCABLE TRUST DURABLE POWER OF ATTORNEY HEALTH CARE SURROGATE LIVING WILL LEGAL DOCUMENTS YES NO DATE

3 Primary Physician's Name, Address & Telephone: Stock Broker Name & Address & Phone: Accountant or CPA Name & Address & Phone: Safe Deposit Box: Name of Bank & Branch & Box #: Who is authorized to enter box? Has Applicant or Spouse ever been in or worked for the following: (Complete this even if Spouse is deceased) Military Service Yes No Private Employer Pension Plan Yes No Federal Government Yes No Trade Union with Pension Plan Yes No State Government Yes No Railroad Retirement Yes No If Applicant served in military, What Branch?: Date of Service: If Spouse served in military, What Branch?: Date of Service: Have you applied for VA BENEFITS (Aid and Attendance)? YES NO Have you started receiving benefits? When? How much per month?

4 PROPERTY Have you made any GIFTS over $1,000 in value within the past 60 months? Yes No If YES, explain in full detail: Have you purchased an Annuity in the last 5 years? Yes No If so, please list Annuity and amount: List all real property owned by Applicant, Spouse, or Applicant and Spouse jointly HOMESTEAD (THE PROPERTY WHERE YOU RESIDE, OR RESIDED BEFORE ADMISSION TO FACILITY) Is this residence a: home mobile home condominium other (describe): Owners on the Deed: How much is presently owed on a mortgage on this property? $ If you were going to sell your home, what price would you expect to receive? $ ALL OTHER REAL ESTATE: PROPERTY ADDRESS: Owners on the Deed: What is the present value of the property? $ How much is presently owed on a mortgage on this property? $ Do you receive rental income? Yes No Monthly Rental Amount $ If there is a written lease, please attach copy of LEASE If other parcels are owned, provide same information on extra page.

5 BURIAL ASSETS 1. Do you own cemetery plots? Applicant Spouse IF YES, ATTACH COPY OF DEED/PAPERWORK ON PLOTS. 2. Do you have any burial contracts or pre-paid funeral agreement for applicant or spouse (please provide copy of each agreement or contract)? APPLICANT: Date of purchase: Name of Funeral Home: Name of Insurance Co: Is contract IRREVOCABLE: Amount $ SPOUSE: Date of purchase: Name of Funeral Home: Name of Insurance Co: Is contract IRREVOCABLE: Amount $ Does Applicant/Spouse have a special bank account set aside for burial funds? (please provide a copy of the bank statement on the account) Yes No LOANS (MORTGAGE AND NOTES FOR MONEY DUE TO YOU) Does Applicant or Spouse OWN a mortgage and/or a promissory note? YES NO LOAN # 1: Names on the note or mortgage: Principal balance remaining due $ What is the monthly payment $ Is the mortgage marketable (can it be sold?) YES NO If marketable, what could you sell it for? $ IS APPLICANT OR SPOUSE THE BENEFICIARY OF ANY TRUSTS (indicate value, assets, distributions available or expected)? Applicant: Spouse: DOES APPLICANT OR SPOUSE EXPECT AN INHERITANCE? Applicant: Spouse:

6 LIFE INSURANCE : (Includes life insurance held by funeral home for burial) Complete the following AND BRING COPIES OF POLICIES FOR THE FILE. Company and Face Cash Loan Balance Policy # Owner Insured Value Value Against Policy LIFE INSURANCE : (Includes life insurance held by funeral home for burial) Complete the following AND BRING COPIES OF POLICIES FOR THE FILE. Company and Face Cash Loan Balance Policy # Owner Insured Value Value Against Policy LONG TERM CARE POLICIES: APPLICANT'S INSURANCE SPOUSE'S INSURANCE Does Applicant or Spouse have any long term care insurance policies? YES NO IF YES, BRING COPIES OF POLICY AND CURRENT PREMIUM STATEMENT. HEALTH/MEDICIAL INSURANCE: Does Applicant have health or medical insurance? YES NO Does Spouse have health or medical insurance? YES NO IF YES, BRING COPIES OF INSURANCE POLICY, CARD, AND CURRENT PREMIUM STATEMENT. List Insured, Policy #, and Name and Address of Insurance Company: APPLICANT: SPOUSE: HOW IS PREMIUM PAID: PORTION OF PREMIUM ATTRIBUTABLE TO APPLICANT: PORTION OF PREMIUM ATTRIBUTABLE TO SPOUSE:

7 MOTOR VEHICLES Does Applicant or Spouse own a vehicle? YES NO Does Applicant or Spouse own a boat? YES NO PLEASE BRING COPY OF VEHICLE/VESSEL TITLE Make/Model/Year Value and Owner Name Does Applicant have current driver's license? YES NO Does Spouse have current driver's license? YES NO If YES, we need a photocopy of driver's license(s) and copy of insurance card. PLEASE BRING MOST RECENT INSURANCE BILL for proof of premium.