VETERANS AID & ATTENDANCE QUALIFICATION WORKSHEET

Size: px

Start display at page:

Download "VETERANS AID & ATTENDANCE QUALIFICATION WORKSHEET"

Sharyl Cox
5 years ago
Views:

VETERANS AID & ATTENDANCE QUALIFICATION WORKSHEET A. PERSONAL DATA Veteran Name: County: Address: Date of Birth: Spouse Name: County: Address: Date of Birth: B.

1 VETERANS AID & ATTENDANCE QUALIFICATION WORKSHEET A. PERSONAL DATA Veteran Name: County: Address: Date of Birth: Spouse Name: County: Address: Date of Birth: B. SERVICE INFORMATION Did the veteran serve during one of the following war-times: WWII 12/07/ /31/1946 Korean War 06/27/ /31/1955 Vietnam Conflict 08/05/ /07/1975 Gulf War 08/02/ Present 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: C. CURRENT HEALTH / HOUSING INFORMATION VETERAN 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. CURRENT HEALTH / HOUSING INFORMATION - SPOUSE 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)? 1

2 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 Retirement Benefits (Gross) VA Disability Benefit Annuity Income Rental Income Total 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. F. MONTHLY UNREIMBURSED MEDICAL EXPENSES ( UME ) 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 2

3 G. MONTHLY SHELTER EXPENSES (Please divide annual expenses by 12 and quarterly expenses by 3) Rent/Mortgage Real Estate Taxes Water Sewer Utilities (Heat, Electric) (1/12 of last 12 months) Homeowner s insurance premium Condominium fees Total Monthly Housing Expenses H. MONTHLY NON-SHELTER EXPENSES (Please estimate) Food Medical Clothing Telephone Transportation (including auto insurance) Home Maintenance Life Insurance Premiums Cable TV Federal and State Income Taxes Other Total Monthly Non-Shelter Living Expenses 3

4 I. ASSETS/LIABILITIES (Please insert the value of each asset/liability in the appropriate space.) Asset Husband Wife Joint Liabilities AUTOMOBILE ADDITIONAL AUTOMOBILE CHECKING ACCOUNT SAVINGS ACCOUNT MONEY MARKET ACCOUNT CERTIFICATES OF DEPOSIT RESIDENCE MUTUAL FUNDS STOCKS BONDS ANNUITIES IRA OTHER REAL ESTATE CARE FACILITY DEPOSIT OTHER OTHER TOTALS J. LIFE INSURANCE COMPANY NAME (include address and policy No.) TYPE DEATH BENEFIT VALUE FACE VALUE CASH VALUE 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. 4

5 K. 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? If so, please state details L. CHILDREN (if applicable) 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? M. PLANNING GOALS Does the veteran/spouse have any intent to benefit their children? Is the veteran/spouse looking for control and independence? N. 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? 5

6 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? O. 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: Additional Comments: 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. 6

ANNUITY PLANNING INTAKE FORM VA AID & ATTENDANCE

ANNUITY PLANNING INTAKE FORM VA AID & ATTENDANCE Information of individual completing this form: Name: Company: Address: City, State, Zip: Telephone: Facsimile: E-Mail: ONCE COMPLETED, RETURN THIS FORM