ANNUITY PLANNING INTAKE FORM VA AID & ATTENDANCE

Transcription

1 ANNUITY PLANNING INTAKE FORM VA AID & ATTENDANCE Information of individual completing this form: Name: Company: Address: City, State, Zip: Telephone: Facsimile: ONCE COMPLETED, RETURN THIS FORM TO: Krause Financial Services 1234 Enterprise Drive, De Pere, WI Phone: (866) Facsimile: (866) A. CLIENT DATA (Veteran) (Spouse) Full Name: Full Name: Street Address: City: State: Zip: (Veteran) (Spouse) Birth Date: Birth Date: B. SERVICE INFORMATION Did the veteran serve during one of the following war-times: WWII 12/07/ /31/1946 Korean Conflict 06/27/ /31/1955 Vietnam Era 08/05/ /07/1975 Gulf War 08/02/1990 N/A If yes, what branch of service, for how long, and what type of discharge did the veteran receive: Branch: Length of Service: Type of Discharge: 1

2 C. VETERAN S HEALTH AND HOUSING INFORMATION Is the veteran alive? (If deceased, the following questions may be disregarded.) Is the veteran suffering from any type of blindness? Does the veteran need any assistance with the following (check all that apply): Eating Bathing Dressing Toileting Transferring Does the veteran suffer from a mental disability (i.e. Alzheimer s)? Does the veteran still operate a motor vehicle? Does the veteran live alone, without any assistance? Does the veteran currently reside in an assisted living facility? Does the veteran currently reside in a nursing facility? Is the veteran receiving care through a caregiver agreement? D. SPOUSE S HEALTH AND HOUSING INFORMATION Is the spouse alive? (If deceased, the following questions may be disregarded.) Is the spouse suffering from any type of blindness? Does the spouse need any assistance with the following (check all that apply): Eating Bathing Dressing Toileting Transferring Does the spouse suffer from a mental disability (i.e. Alzheimer s)? Does the spouse still operate a motor vehicle? Does the spouse live alone, without any assistance? Does the spouse currently reside in an assisted living facility? Does the spouse currently reside in a nursing facility? Is the spouse receiving care through a caregiver agreement? E. MONTHLY INCOME Veteran s Monthly Income Spouse s Monthly Income Social Security Benefits Pension (Gross) VA Disability Benefit Other Income* Total Monthly Income *If other, please explain: 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. 2

3 F. UNREIMBURSED RECURRING MEDICAL EXPENSES Veteran s Monthly URME Spouse s Monthly URME Nursing Home $ $ Assisted Living $ $ Home Health Care $ $ Medicare Premiums $ $ Insurance Premiums $ $ Health Insurance Premiums $ $ Medicare Supplemental $ $ Insurance Premiums Monthly Prescription Cost $ $ Monthly Other Cost $ $ Total Monthly UME $ $ G. MONTHLY SHELTER EXPENSES Rent/Mortgage Real Estate Taxes Water/Sewer Utilities (Heat, Electric) Homeowner s insurance premium Other Total Monthly Housing Expenses H. MONTHLY NON- SHELTER EXPENSES (Please estimate) Food Telephone Transportation (including auto insurance) Home Maintenance Life Insurance Premiums Federal and State Income Taxes Other Total Monthly Non-Shelter Living Expenses 3

4 I. ASSETS/LIABILITIES Please insert the current value of each asset/liability in the appropriate space. Specify whether multiple accounts or one account for each type of asset. Asset Veteran Spouse Joint Liability AUTOMOBILE ADDITIONAL AUTOMOBILE CHECKING ACCOUNT SAVINGS ACCOUNT OTHER BANK ACCOUNTS RESIDENCE MUTUAL FUNDS STOCKS/BONDS ANNUITIES RETIREMENT ACCOUNTS ROTH IRAs OTHER REAL ESTATE CARE FACILITY DEPOSIT OTHER OTHER TOTAL Does the veteran own an irrevocable Funeral Expense Trust? Does the spouse own an irrevocable Funeral Expense Trust? Are there any additional liabilities that should be considered (credit card debt, personal loans, outstanding medical bills, etc.)? If yes, please explain: J. LIFE INSURANCE TYPE DEATH BENEFIT VALUE FACE VALUE CASH VALUE INSURED OWNER 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. 4

5 K. GIFTS Has either spouse made gifts in excess of $ in any one month, to an individual or group of individuals, within the past 60 months? If yes, please explain: L. POWER OF ATTORNEY (if applicable) Veteran: Name of agent(s): States of residence: If multiple agents are designated, are they required to act jointly? Spouse: Name of agent(s): States of residence: If multiple agents are designated, are they required to act jointly? M. THIRD PARTY COMPENSATION If there is a licensed insurance agent, financial advisor, or other person seeking compensation on this case, Krause Financial Services must know of their relationship prior to the development of an annuity plan. As to commission producing insurance products wherein a planning proposal 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? 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? Yes No 5

6 N. 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 an 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 VA eligibility. Dated: Signature of Client or Client Representative: By way of this letter, Krause Financial Services, and its agents, are not offering legal advice. The content outlined in this communication may not be suitable for every individual, in every state. As such, before employing or acting upon any one, or more, of the techniques, strategies, or opinions discussed in this letter, 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 the purchase of any insurance products will result in eligibility for Medicaid or any other assistance program. 6