Street Address. Oiagnosis. Prognosis. Course of Treatment,

Transcription

1 ASSET PRESERVATION I MEDICAID QUESTIONNAIRE (SINGLE) Oate Home Phone No. File Number --- (For Office Use Only) Business Phone No. This form is extremely important. Your accuracy and completeness in responding will help us best represent you. Please bring this information with you to the appointment. A. PERSONAL DATA Full Name Street Address City ~ State Zip Birth Social Security No.. U,S. Citizen? Yes.- No --- Veteran? Yes No B. MEDICAL DATA 1. HEALTH Oiagnosis Prognosis Course of Treatment, If you are already in a nursing home, please indicate the name of the nursing home and the date first entered.

2 2. PHYSICIAN Full Name of Primary Physician. Street Address City State Zip C. MONTHL Y INCOME Social Security Benefits $ (include $54 Medicare Part B Deduction, if applicable) Retirement Benefits (Gross) $ Veterans Disability Benefit $ Annuity Income $ Rental Income $ TOTAL MONTHL Y INCOME $ 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. Could this pension amount increase in the future? Yes, No --- Do not include interest and dividend income on this form. D. MONTHLY COST OF NURSING HOME Monthly Nursing Home Cost $...;..., Monthly Other Cost $, Total Monthly Cost The nursing home is paid through, (month/year). -2-

3 E. GIFTS Please list all gifts made to an individual or group of individuals, within the past 60 months: Have you ever filed a Federal Gift Tax Return? Yes No If so, please state details -3-

4 F. LIFE INSURANCE COMPANY NAME TYPE DEATH FACE CASH INSURED OWNER BENEFICIARY (include address BENEFIT VALUE VALUE and VALUE policy #) (Include the cash value of the life insurance on the life insurance line in Section G) It is verj 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 G. CHILDREN (if applicable) CHILD'S ADDRESS TELEPHONE DATE OF SOCIAL NAME (WITH ZIP NUMBER BIRTH SECURITY CODE) NUMBER Are all of your children in good health? Yes No Are any of your children blind? Yes No Are any of your children disabled? Yes No Are any of your children receiving SSI of other form of government entitlement? Yes No Are any of your children or other family members living with a chronic disease or terminal illness? Yes No Do any of your family members have any problems with: Drug Addiction? Yes No Alcoholism? Yes No Spendthrift? Yes No Do any of your relatives (children, siblings, etc.) live with you in your home? Yes No If yes, name of relative. -5-

6 H. CLIENT ASSET INFORMATION PERSONAL PROPERTY (Autos, Mobile Homes, R. V.s, Boats, Art, Antiques, Jewelry) Description of Property Value How Titled? Insured? TOTAL VALUE OF PERSONAL PROPERTY: $ REAL ESTATE For each listing, indicate type of property, i.e., condominium, co-op, mobile home, timeshare, land, single residence, multifamily residence, etc. Please use back of page, if necessary. Primary Residence: Address: Type of Property: If a mobile home, do you own the ground? Names as they appear on deed: Acquired: Current Value: Mortgage Company: Telephone No. of Mortgage Company: ~ Cost of improvements made? Homestead exemption? How much? Senior citizen exemption? How much? VA exemption? How much? Star Exemption? How much? Purchase Price: Mortgage Balance: Investment Property #1: Address: Type of Property:. If a mobile home, do you own the ground? Names as they appear on deed: Acquired: Purchase Price: Current Value: Mortgage Balance: Mortgage Company: Telephone No. of Mortgage Company: -6-

7 Cost of improvements made? Homestead exemption? How much? Senior citizen exemption? How much? VA exemption? How much? Star Exemption? How much? Investment Property #2: Address:. Type of Property: If a mobile home, do you own the ground?. Names as they appear on deed: Acquired: Purchase Price: Current Value: Mortgage Balance: Mortgage Company: Telephone No. of Mortgage Company: Cost of improvements made? Homestead exemption? How much? Senior citizen exemption? How much? VA exemption? How much? Star Exemption? How much? Total value of real estate: $ Less outstanding mortgages: $ Equity in real estate: $ INTANGIBLE ASSETS List Bank Accounts (including custodial accounts), CDs, Brokerage Accounts, Stocks, Bonds, Annuities, Mutual Funds. This section must be completed in full. Please bring the most recent statement for each asset to the appointment. If the asset is an IRA, Keogh or 401(k) p/c.ln,please list in the next section. Please use the back of this page, if necessary. Type of Asset Name & Address of Financiallnstitution: Telephone No. of Financiallnstitution: How~theassettitled?: ~ Value: "'-$. Maturity date?: Type of Asset Account #: Beneficiary: Interest rate: Annual interest earned? APY rate: Name & Address of Financiallnstitution: Telephone No. of Financiallnstitution: How is the asset titled?: Value: ""'$ Maturity date?: Type of Asset Account #: Beneflciary.j, Interest rate: Annual interest earned? APY rate: Name & Address of Financiallnstitution:. Telephone No. of Financiallnstitution: -7-

8 Howistheassettitled?:,~~~~~~~~~~~~~~~~~~~.~~~~~~~~~ Value:.:::$~~~~~ Account #:,~~~~~Beneficiary:,~~~~~~ ~ Maturity date?:,~ Interest rate: Annual interest earned?~~~ APY rate: Type of Asset:~~~~~~~~~~~~~~~~~~ ~~~~~~~ Name & Address of Financial Institution:~~ ~~~~~~.~~~~~~ Telephone No. of Financiallnstitution:~ ~~~ How is the assettitled?:~~~~~~~~~~~~~~~~.~~~~~ ~~ Value: ","$~~~~~ Account #:~~ Beneficiary:~ ~~~~ Maturity date?:,~ Interest rate: Annual interest earned?~~ APY rate: Type of Asset:~~~~~~ ~~~~~~~.~~ ~~~~ ~~~ Name & Address of Financiallnstitution:~~~~~~~~~~ ~ ~ Telephone No. of Financiallnstitution: How is the asset titled?:~~~~~ ~~ ~~~ ~~ Value: ","$~~~~ Maturity date>: Account #: Beneficiary:~~~~.~~~~ Interest rate: Annual interest earned? APY rate: Total intangible assets: $~~~~ ~ IRA, KEOGH AND/OR 401(K) PLANS Type of Asset: ~ Name & Address of Co.: ~~~~~~~~~~~~~ ~~~~~.~~ Telephone No. of Company: ~~~~~~ How is the asset titled?:~~~~~~~~~~~~~ ~~ ~~~~ ~ Value: ~$~~~~~~~~ Account #:~~~~ ~~~ ~ Beneficiary: Maturity date?:~ Interest rate: APY rate: Annual retirement income?~~~~~ Pre-retirement death benefit,~ Cost of living adjustment? ~ Non-deductible employee contribution to date. ~~Annual employer contribution, Annual employee contribution,~~~~~~~~ Life Expectancy Method chosen:~ Minimum distribution:,~~~~~ TypeofAsset:~~~~~~~~~~~~~~~~ ~~~~~~~~ Name & Address of Co.:~~~~~ ~~~~~~~~~~~~~~~~~ Telephone No. of Company:~~~~ ~~ How is the asset titled?:~~~ ~~~~~~~ ~~~~ Value: ~$ ~ Account #:, ~ Beneficiary: Maturity date?:, Interest rate: APY rate: Annual retirement income? Pre-retirement death benefit~ ~~~~ Cost of living adjustment? Non-deductible employee contribution to date, ~---,Annual employer contribution,~ Annual employee contribution,~~~~~~~ Life Expectancy Method chosen: Minimum distribution:~ -8-

9 Type of Asset, Name & Address of Co.: Telephone No. of Company: How is the asset titled?: Value: :±:$ Account #: Beneficiary: Maturity date?: Interest rate: APY rate: Annual retirement income? Pre-retirement death benefit, Cost of living adjustment? Non-deductible employee contribution to date Annual employer contribution, Annual employee contribution Life Expectancy Method chosen: Minimum distribution: Type of Asset Name&Add~ ~Co.: Telephone No. of Company: How is the asset titled?: Value: ~$ Account #: Beneficiary: Maturity date?:, Interest rate: APY rate: Annual retirement income? Pre-retirement death benefit, Cost of living adjustment? Non-deductible employee contribution to date Annual employer contribution Annual employee contribution Life Expectancy Method chosen: Minimum distribution: Total IRA, Keogh or 401 (k) assets: $ LIABILITIES Mortgages: $, Notes to Others.S Credit Card Bills:$, Other: $, Notes to Banks.S Unpaid Medical.S Car Loans: $, Total Liabilitles.S -9-

10 I. MISCELLANEOUS Do you have any other legal issues which I should be aware of: Yes No If yes, please explain: ~ ' J. REFERRAL By Whom Were You Referred To This Office? Name: Address: City State Zip K. CERTIFICATION The undersigned hereby represents to Tamra K. Waltemath, P.C., and each of its attorneys, that the information contained in this intake form is accurate and complete, and that the undersigned understands that the law firm and its individual lawyers will rely on this information. I understand if the information contained herein is inaccurate or incomplete, the recommendations made by the law firm may not be appropriate. Signature of Client or Client Representative: -10-