MEDICAID COMPLIANT ANNUITY PLANNING QUESTIONNAIRE SINGLE PERSON

Transcription

1 MEDICAID COMPLIANT ANNUITY PLANNING QUESTIONNAIRE A. PERSONAL DATA SINGLE PERSON Name: Address: City, State, Zip: Telephone: Facsimile: Client Full Name Street Address City State Zip Birth Date U. S. Citizen? Veteran? Surviving Spouse of Veteran? Yes No B. MEDICAL DATA Diagnosis Prognosis Course of Treatment Residence of Individual Home Nursing Home Assisted Living Facility If individual has already entered a care facility, please indicate the name of the facility and the first date entered on a continuous basis 1

2 C. MONTHLY INCOME Social Security Benefit Retirement Benefit (Gross) VA Disability Benefit Annuity Income Rental Income Total Monthly Income Monthly Income Do not include interest and dividend income on this form. If there is a pension, please list the gross pension amount, including any monies taken out for federal income taxes, health insurance, or any other reason. D. MONTHLY COST OF CARE Monthly Facility Cost Health Insurance Premiums Medicare Supplemental Insurance Premiums Monthly Incidental Cost Monthly Prescription Cost Monthly Other Cost Total Monthly Costs The care facility is paid through (month/year). If the nursing home facility is located in New Hampshire, Kansas, Ohio, or Pennsylvania Krause Financial Services, LLC, will require the care facility s Medicaid per diem rate to develop the appropriate Medicaid Compliant Annuity Plan. As such, if applicable, please provide the Medicaid per diem rate: $ 2

3 E. ASSETS/LIABILITIES (Please insert the value of each asset/liability in the appropriate space.) Asset Value Liability AUTOMOBILE ADDITIONAL AUTOMOBILE CHECKING ACCOUNT SAVINGS ACCOUNT MONEY MARKET ACCOUNT CERTIFICIATES OF DEPOSIT RESIDENCE MUTUAL FUNDS STOCKS BONDS ANNUITIES IRA OTHER REAL ESTATE CARE FACILITY DEPOSIT OTHER OTHER TOTALS F. LIFE INSURANCE COMPANY NAME (include address and policy No.) TYPE DEATH BENEFIT FACE CASH INSURED OWNER BENEFICIARY It is very important to know the cash value and the death benefit of your life insurance policy. To obtain the cash value of the policy, please call your insurance agent, or call the insurance company directly. 3

4 G. GIFTS Please list gifts made in excess of $ in any one month, to an individual or group of individuals, within the past 60 months: Have you ever filed a Federal Gift Tax Return? H. CHILDREN (if applicable) CHILD S NAME ADDRESS (With Zip Code) TELEPHONE NUMBER DATE OF BIRTH Are all of your children in good health? Are any of your children receiving SSI or other forms of government entitlement? Do any of your children live with you in your home? I. THIRD PARTY COMPENSATION If a licensed insurance agent, financial advisor, or other person is seeking compensation on this case, Krause Financial Services must know of their relationship prior to the development of a Medicaid plan. As to commission producing insurance products wherein a planning letter has been devised, the compensation will be divided 50/50 between the insurance agent and Krause Financial Services. The agent is required to become appointed at the respective insurance company and the commission split must be designated on the insurance product application sent through Krause Financial Services. Will a third party be seeking compensation in this transaction? 4

5 Has the proposed applicant retained the services of an elder law attorney that will render all legal advice regarding Veterans and/or Medicaid benefits and the ultimate purchase of an insurance product? J. CERTIFICATION The undersigned hereby represents to Krause Financial Services that the information contained in this intake form is accurate and complete, and that the undersigned understands that Krause Financial Services will rely on this information for purposes of developing a Medicaid Annuity plan. The undersigned hereby further understands that if information is omitted from this intake form, whether intentionally or unintentionally, that the information omitted may have a direct, and negative, impact on Medicaid eligibility. Dated: Signature of Client or Client Representative: Once completed, please return this form to: 1 Krause Financial Services, LLC Dale M. Krause, J.D., LL.M Enterprise Drive De Pere, WI Phone: (866) Facsimile: (866) info@medicaidannuity.com Or make a quote request online at Krause Financial Services is a limited liability company in the State of Wisconsin. Dale M. Krause, and Krause Financial Services, LLC, by means of this letter, is not offering legal advice. With respect to the material contained in this letter, some of the material may be affected by current and future changes in law. For those reasons, the accuracy and completeness of such information, and the opinions of its author, are not guaranteed. In addition, because of the complexity and interrelationship of various areas of law which are presented in this letter, from which there may be certain exceptions or limitations, the strategies and plans outlined in this letter may not be suited for every individual, in every state. As such, it is strongly suggested that before employing any one, or more, of the techniques, strategies, expositions of any law, the reader should secure the services of a competent elder law attorney in their respective state. Furthermore, no inference is to be drawn that any of the insurance products provided by Krause Financial Services have been reviewed or approved by any state Medicaid office. Krause Financial Services makes no guarantee that purchase of any insurance products will result in eligibility for Medicaid or any other assistance program. 5