Long Term Care Planning Survey Form Note: If applicant is married, information is required for applicant AND spouse

Transcription

1 Page 1 of 7 / Section 1 General Information (continued) Long Term Care Planning Survey Form Note: If applicant is married, information is required for applicant AND spouse Today s Date SECTION 1: GENERAL INFORMATION Name of Applicant Home Address or Nursing Home Address City State Zip If in nursing home, date of admission Date of birth Soc Sec # Spouse Information: Name Date of Marriage Date of Birth Soc Sec # If deceased, date of death Spouse Address Home Phone Work Phone Cell Phone Alternate/2 nd Address City State Zip Code Alternate Home Phone number Name of Person/Company who referred you to this firm May we thank the referral person? Yes No Name, Address & Tel. No. of person filling out this form (if other than client) Children of Applicant & Spouse (include children from prior marriages, if any):

2 Page 1 of 7 / Section 1 General Information (continued) Children (continued): Additional children or friends/relatives/others assisting in the long-term care planning process: Please attach an additional sheet for additional children or contacts*

3 Page 3 of 7 / Section 2 Assets and Form of Ownership Real Estate Home SECTION 2: ASSETS & FORM OF OWNERSHIP Does applicant or spouse own his/her own home? Yes No If yes, answer the following: Street Address Approx : $ Total Mortgage Due $ Monthly Mortgage Payment $ Ownership: & Spouse Only & Other: & Other: Other Real Property Owned Street Address Approx : $ Total Mortgage Due $ Monthly Mortgage Payment $ Ownership: & Spouse Only & Other: & Other: Street Address Approx : $ Total Mortgage Due $ Monthly Mortgage Payment $ Ownership: & Spouse Only & Other: & Other: IRAs, 401Ks Bank or Brokerage Acct # Owner Approx $

4 Page 4 of 7 / Section 2 Assets and Form of Ownership (continued) Bank Accounts (all accounts held in the past 60 months. Exclude IRA and retirement type accounts) Acct #5 Acct #6 Acct #7 Acct #8 Acct #9 0 Bank Name Acct # Account Type Owner & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other Approx $ If closed date closed

5 Page 5 of 7 / Section 2 Assets and Form of Ownership (continued) Annuities Annuity #1 Annuity #2 Annuity #3 Annuity #4 Company & Policy # Approx $ Owner Annuitant s Name & Spouse & Spouse & Spouse & Spouse Life Insurance Policy #1 Policy #2 Policy #3 Company Policy# Owner Insured Face Cash Surrender Brokerage Accounts (those held past 60 months WITH a broker. Exclude IRA/Retirement Type) Broker Name Acct# Owner & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other Approx If closed, date closed

6 Page 6 of 7 / Sections 2, 3, 4 & 5 Assets and Form of Ownership (continued), Transfers, Income & Additional Questions Individually Held Stocks, Bonds, Mutual Funds (Exclude IRA/Retirement type) Acct #5 Stock/Bond/ Mutual Fund Owner & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other & Spouse & Other & Other Approx If closed, date closed Any other assets not listed above. Please provide type, ownership, value: SECTION 3: TRANSFERS Have you given away/transferred any assets or sold real property in the past 5 years? Yes No If yes, answer the following: Transfer #1 Transfer #2 Transfer #3 Transfer #4 Type of Property/Asset Type of Transfer Date of Transfer SECTION 4: INCOME Soc Sec/Month Pension/Month Veterans Benefits/Month Other Income/Month Applicant Spouse SECTION 5: ADDITIONAL QUESTIONS Does the applicant or spouse have a CHILD who is disabled or receiving Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI)?... Yes No

7 Page 7 of 7 / Section 5 & 6 Additional Questions (continued) & Your Comments and Questions Regarding the Applicant: Do you have long term care insurance?... Yes No Has prepaid funeral?... Yes No If yes, funeral director Has burial plot?... Yes No Owns automobile?... Yes No Has safe deposit box?... Yes No Has healthcare proxy?... Yes No Has living will?... Yes No Has trust?... Yes No Has power of attorney?... Yes No If yes, who is agent? Has Medicare?... Yes No If yes, ID # Part A Part B Has private health insurance?... Yes No If yes, company: ID# Premium/Month A Veteran?... Yes No If yes, dates of service: Expecting an inheritance?... Yes No US Citizen?... Yes No If applicant s spouse is deceased, was applicant s spouse a veteran?... Yes No Regarding the Spouse: Veteran?... Yes No Expecting an inheritance?... Yes No Has Medicare?... Yes No If yes, ID # Part A Part B Has private health insurance?... Yes No If yes, company: ID# Premium/Month SECTION 6: YOUR COMMENTS & QUESTIONS Please use this area for any additional information, comments or questions: