Questionnaire for estate planning involving special needs trusts Married couple

Transcription

1 Questionnaire for estate planning involving special needs trusts Married couple

2 Date: CONFIDENTIAL Hickman-Lowder.com ESTATE PLANNING QUESTIONNAIRE (MARRIED CLIENTS) PART 1 YOUR FAMILY Personal Information Spouse #1 Spouse #2 Full Name Street Address City, State, Zip County Home Phone Work Phone Cell Phone Address Occupation/Position Employer/ Employer Address US Citizen? Yes No Yes No Date of Birth Social Security No. Previous marriages? Yes No Yes No Pay child support? Pay alimony? List all health insurance (include long term care policies) Hickman & Lowder Co., L.P.A. Page 1 Estate Planning Questionnaire

3 Medical Information Describe the current state of health of both partners. Children Full Name Address & Phone Birth Date Spouse s Name Children (Names and Ages) Identify Children From a Previous Relationship Spouse #1: Spouse #2: Hickman & Lowder Co., L.P.A. Page 2 Estate Planning Questionnaire

4 Other Dependents (e.g. parents) Full Name Address & Phone Birth Date Relationship Family Members with Special Needs If you have a child or other family member with physical or mental disabilities, please provide additional information here including name, social security number, nature of the disability, and any public benefits received. Family Members with Other Challenges If you have a child or other family member with a chronic illness, substance abuse problem or addiction, or difficulty managing money, please provide additional information here. Hickman & Lowder Co., L.P.A. Page 3 Estate Planning Questionnaire

5 PART 2 - FINANCIAL SUMMARY Assets BANK ACCOUNTS- CHECKING/SAVINGS/CDs (List bank, type, and account no.) SPOUSE #1 SPOUSE #2 JOINT BANK ACCOUNTS - IRA REAL ESTATE (Provide address) STOCKS (List company and no. of shares) BONDS (List type and number) MUTUAL FUNDS (Indicate company) BROKERAGE ACCOUNTS (Indicate company) RETIREMENT SAVINGS 401K/PENSION (Indicate company) Hickman & Lowder Co., L.P.A. Page 4 Estate Planning Questionnaire

6 ANNUITIES (Indicate issuer) LIFE INSURANCE PRIVATE (List insurer, type of policy, & death benefit) LIFE INSURANCE EMPLOYER (List insurer, type of policy, & death benefit) AUTOMOBILES (List year, make, & model) MONEY OWED TO YOU (Describe) BUSINESS INTEREST YOU OWN (Describe) OTHER ASSETS - JEWELRY/COLLECTIONS (Describe) Annual Income (Not From Investments) SALARY/WAGES (Indicate employer) SPOUSE #1 SPOUSE #2 JOINT RETIREMENT/RENTAL/OTHER INCOME (Describe) Hickman & Lowder Co., L.P.A. Page 5 Estate Planning Questionnaire

7 Liabilities DEBT (Describe type & to whom owed) SPOUSE #1 SPOUSE #2 JOINT PART 3 - ESTATE PLAN CHOICES Executor - The executor is the person nominated in your Will and appointed by the probate court to handle matters after your death. The executor must collect, manage and, if necessary, sell your property; pay your debts and taxes; and then distribute what is left as you specify. The executor will report to the probate court about those activities. The executor is also responsible for other tasks--for example, terminating leases and credit cards, and notifying people and organizations of your death. Please list at least two individuals, in order of preference, who you want to serve as executor and backup executor(s), and their relationship to you: Spouse #1 Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Spouse #2 Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Guardian(s) - A guardian is an adult (or a corporation or public agency) nominated by you and appointed by the probate court, who will act on behalf of your minor or incapacitated adult child if you both die or become incapacitated yourselves. The guardian manages the financial and/or personal affairs of that child. If your child(ren) need a guardian, please list who you want to serve as guardian and backup guardian(s), and their relationship to you: Name 1 st Choice 2 nd Choice 3 rd Choice Relationship Hickman & Lowder Co., L.P.A. Page 6 Estate Planning Questionnaire

8 Financial Power of Attorney - In this power of attorney you share authority with another (your agent) to manage your financial matters and your property as needed while you are alive. Please list at least two individuals who you want to serve as agent and backup agent(s), and their relationship to you: Spouse #1 Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Spouse #2 Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Health Care Power of Attorney - In a health care power of attorney you authorize another to make medical decisions for you if you are not able. Please list at least two individuals who you choose to serve in this role, and their relationship to you: Spouse #1 Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Spouse #2 Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Living Will Declaration - Some people want to discontinue life sustaining treatment if they are terminally ill and that treatment serves only to prolong their dying. A living will becomes your voice if you are unable to express this choice at the end of life. It also contains similar instruction should you be in a persistent vegetative state. Spouse #1 Do you want a living will? Yes No Spouse #2 Do you want a living will? Yes No HIPPA Authorization - This document authorizes your medical providers to share information about your health care and status with the people you choose. If there are any members of your immediate family (spouse and children) that you want to exclude please identify them: If there is anyone outside of your immediate family that you want to include, identify their name and relationship to you: Hickman & Lowder Co., L.P.A. Page 7 Estate Planning Questionnaire

9 Trustee - A trust may be needed as part of your estate plan if, for example, you have minor children, a family member with a disability, real estate located in several different states, or estate tax concerns. The trustee is an individual, or a bank or trust company, who manages the trust property according to the directions that you give in the trust agreement. In a trust, the person who creates it (i.e., you) is usually the initial trustee. Please list at least two individuals or entities who you want to serve as trustee and backup trustee(s) and their relationship to you: Spouse #1 Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Spouse #2 Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Contact Information (Other than immediate family) - Please provide all contact information for any individuals other than yourselves or your children whom you have identified above. Name Address Phone Numbers Hickman & Lowder Co., L.P.A. Page 8 Estate Planning Questionnaire

10 PART 4 GENERAL QUESTIONS Miscellaneous Please check the boxes below if they are applicable to you. SPOUSE #1 SPOUSE #2 Do you have an existing Will? Location: Have you signed an Advance Directive or Health Care Power of Attorney? Do you have a safe deposit box? Location: Have you made gifts to a person other than your partner in excess of 10,000 in any one calendar year? Have you ever filed a Federal Gift Tax Return? Do you own or operate any business? Do you expect to receive an inheritance other than from each other? Do you have a pre-nuptial or post-nuptial agreement? Do you serve as agent under a power of attorney or as guardian for anyone? Describe: Have you established a Trust, or are you a beneficiary of a Trust? Are you a veteran of the armed forces? If yes, name branch and dates of induction & discharge: Do you have a prepaid funeral or cemetery plot? If yes, name the funeral home/cemetery: Do you file Federal income tax returns? Special Estate Planning Objectives and Other Legal Concerns - Describe any special estate planning objectives or other legal concerns. Hickman & Lowder Co., L.P.A. Page 9 Estate Planning Questionnaire

11 The undersigned states that the information contained above is accurate and complete. Hickman & Lowder will rely on this information, and the undersigned acknowledges that if it is inaccurate or incomplete the recommendations made by the law firm may not be appropriate. Spouse#1 Spouse #2 Date Date Please bring the following documents with you to your meeting with the attorney: 1. Will, codicil, trust agreements 2. Life insurance and annuity policies and beneficiary designation forms 3. Statements of account for savings and checking accounts 4. Brokerage statements for stocks, bonds, and securities or copies of certificates and bonds 5. Guardianship documents, if applicable 6. Living will, advance directive, power of attorney, durable power of attorney 7. Employee or retiree benefit statements (beneficiary designations on IRA's, Keoghs, or other retirement plan), including current beneficiary designation 8. Business papers: operating agreement, partnership agreement, corporate minute books, buy/sell agreements Hickman & Lowder Co., L.P.A. Page 10 Estate Planning Questionnaire

12 Questionnaire for estate planning involving special needs trusts Single client

13 Date: CONFIDENTIAL Hickman-Lowder.com ESTATE PLANNING QUESTIONNAIRE (SINGLE CLIENT) PART 1 YOUR FAMILY Personal Information Full Name Street Address City, State, Zip County Home Phone Cell Phone Work Phone Address Occupation/Position Employer/ Employer Address Date of Birth US Citizen? Yes No Social Security No. List all health insurance (include long term care policies) Your Spouse Complete section only if ever married. Full Name Marriage ended by Death Divorce Date of Location of Death/Divorce Death/Divorce Do you have a pre-nuptial or post-nuptial agreement? Yes No Pay Alimony? Pay Child Support? Hickman & Lowder Co., L.P.A. Page 1 Estate Planning Questionnaire

14 Medical Information Describe your current state of health. Children Full Name Address & Phone Birth Date Spouse s Name Children (Names and Ages) Other Dependents (e.g. parents) Full Name Address & Phone Birth Date Relationship Hickman & Lowder Co., L.P.A. Page 2 Estate Planning Questionnaire

15 Family Members with Special Needs If you have a child or other family member with physical or mental disabilities, please provide additional information here including name, social security number, nature of the disability, and any public benefits received. Family Members with Other Challenges If you have a child or other family member with a chronic illness, substance abuse problem or addiction, or difficulty managing money, please provide additional information here. Hickman & Lowder Co., L.P.A. Page 3 Estate Planning Questionnaire

16 PART 2 - FINANCIAL SUMMARY Assets BANK ACCOUNTS- CHECKING/SAVINGS/CDs VALUE (List bank, type, and account no.) BANK ACCOUNTS - IRA REAL ESTATE (Provide address) STOCKS (List company and no. of shares) BONDS (List type and number) MUTUAL FUNDS (Indicate company) BROKERAGE ACCOUNTS (Indicate company) RETIREMENT SAVINGS 401K/PENSION (Indicate company) CO-OWNER (IF ANY) Hickman & Lowder Co., L.P.A. Page 4 Estate Planning Questionnaire

17 ANNUITIES (Indicate issuer) LIFE INSURANCE PRIVATE (List insurer, type of policy, & death benefit) LIFE INSURANCE EMPLOYER (List insurer, type of policy, & death benefit) AUTOMOBILES (List year, make, & model) MONEY OWED TO YOU (Describe) BUSINESS INTEREST YOU OWN (Describe) OTHER ASSETS - JEWELRY/COLLECTIONS (Describe) Annual Income (Not From Investments) SALARY/WAGES (Indicate employer) RETIREMENT/RENTAL/OTHER INCOME (Describe) Hickman & Lowder Co., L.P.A. Page 5 Estate Planning Questionnaire

18 Liabilities DEBT (Describe type & to whom owed) PART 3 - ESTATE PLAN CHOICES Executor - The executor is the person nominated in your Will and appointed by the probate court to handle matters after your death. The executor must collect, manage and, if necessary, sell your property; pay your debts and taxes; and then distribute what is left as you specify. The executor will report to the probate court about those activities. The executor is also responsible for other tasks--for example, terminating leases and credit cards, and notifying people and organizations of your death. Please list at least two individuals, in order of preference, who you want to serve as executor and backup executor(s), and their relationship to you: Name 1 st Choice 2 nd Choice 3 rd Choice Relationship Guardian(s) - A guardian is an adult (or a corporation or public agency) nominated by you and appointed by the probate court, who will act on behalf of your minor or incapacitated adult child if you die or become incapacitated. The guardian manages the financial and/or personal affairs of that child. If your child(ren) need a guardian, please list who you want to serve as guardian and backup guardian(s), and their relationship to you: Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Hickman & Lowder Co., L.P.A. Page 6 Estate Planning Questionnaire

19 Financial Power of Attorney - In this power of attorney you share authority with another (your agent) to manage your financial matters and your property as needed while you are alive. Please list at least two individuals who you want to serve as agent and backup agent(s), and their relationship to you: Name 1 st Choice 2 nd Choice 3 rd Choice Relationship Health Care Power of Attorney - In a health care power of attorney you authorize another to make medical decisions for you if you are not able. Please list at least two individuals who you choose to serve in this role, and their relationship to you: Name Relationship 1 st Choice 2 nd Choice 3 rd Choice Living Will Declaration - Some people want to discontinue life sustaining treatment if they are terminally ill and that treatment serves only to prolong their dying. A living will becomes your voice if you are unable to express this choice at the end of life. It also contains similar instruction should you be in a persistent vegetative state. Do you want a living will? Yes No HIPPA Authorization - This document authorizes your medical providers to share information about your health care and status with the people you choose. If there are any members of your immediate family (children) that you want to exclude please identify them: If there is anyone outside of your immediate family that you want to include, identify their name and relationship to you: Trustee - A trust may be needed as part of your estate plan if, for example, you have minor children, a family member with a disability, real estate located in several different states, or estate tax concerns. The trustee is an individual, or a bank or trust company, who manages the trust property according to the directions that you give in the trust agreement. In a trust, the person who creates it (i.e., you) is usually the initial trustee. Please list at least two individuals or entities who you want to serve as trustee and backup trustee(s) and their relationship to you: Name 1 st Choice 2 nd Choice 3 rd Choice Relationship Hickman & Lowder Co., L.P.A. Page 7 Estate Planning Questionnaire

20 Contact Information (Other than immediate family) - Please provide all contact information for any individuals other than your children whom you have identified above. Name Address Phone Numbers PART 4 GENERAL QUESTIONS Miscellaneous Please check the boxes below if they are applicable to you. Do you have an existing Will? Location: Have you signed an Advance Directive or Health Care Power of Attorney? Do you have a safe deposit box? Location: Have you made gifts to a person in excess of 10,000 in any one calendar year? Have you ever filed a Federal Gift Tax Return? Do you own or operate any business? Do you expect to receive an inheritance? Do you serve as agent under a power of attorney or as guardian for anyone? Describe: Have you established a Trust, or are you a beneficiary of a Trust? Are you a veteran of the armed forces? If yes, name branch and dates of induction & discharge: Do you have a prepaid funeral or cemetery plot? If yes, name the funeral home/cemetery: Do you file Federal income tax returns? Hickman & Lowder Co., L.P.A. Page 8 Estate Planning Questionnaire

21 Special Estate Planning Objectives and Other Legal Concerns - Describe any special estate planning objectives or other legal concerns. The undersigned states that the information contained above is accurate and complete. Hickman & Lowder will rely on this information, and the undersigned acknowledges that if it is inaccurate or incomplete the recommendations made by the law firm may not be appropriate. Name Date Please bring the following documents with you to your meeting with the attorney: 1. Will, codicil, trust agreements 2. Life insurance and annuity policies and beneficiary designation forms 3. Statements of account for savings and checking accounts 4. Brokerage statements for stocks, bonds, and securities or copies of certificates and bonds 5. Guardianship documents, if applicable 6. Living will, advance directive, power of attorney, durable power of attorney 7. Employee or retiree benefit statements (beneficiary designations on IRA's, Keoghs, or other retirement plan), including current beneficiary designation 8. Business papers: operating agreement, partnership agreement, corporate minute books, buy/sell agreements Hickman & Lowder Co., L.P.A. Page 9 Estate Planning Questionnaire

22 Special Needs Trust Questionnaire

23 SPECIAL NEEDS TRUST QUESTIONNAIRE Trust Funded with Beneficiary s Assets This form is important. Your accurate and complete responses will help us best serve you. A. BENEFICIARY S PERSONAL DATA Full Name Street Address Birth Date City State Zip County Type of Residence (Private home or apt., group home, ICF-MR, etc.) Phone No. Driver License /State I.D. No. Social Security No. (copy of card required) U.S. Citizen Yes No B. BENEFICIARY S MEDICAL DATA Medicaid Case No. (copy of card required) County Medicaid Office Address Medicaid Caseworker Phone Fax Medicare Claim No. (copy of card required) Other Medical Insurance (copy of card required) Date of Accident or Injury (if any) Date Funds Received (if any) Nature of Disability C. BENEFICIARY S INCOME AND RESOURCES Employer Phone No. Address Monthly Earned Income Gross Net Monthly SSI (provide recent award letter) Monthly SSDI (provide recent award letter) Monthly Child Disability Benefit (provide recent award letter) Social Security Office Address Social Security Caseworker Phone Fax Other income (child support, alimony, annuity payments, etc.) Reason for Special Needs Trust Personal Injury Settlement Back Payment from Social Security Inheritance Accrual of Savings Other

24 What is the value of the assets and where are they currently held? D. BENEFICIARY S OTHER BENEFITS Home Care Waiver I/O Waiver Level One Waiver PASSPORT Other Waiver Food Assistance Section 8 or Public Housing Veterans Benefits PERS STRS Railroad Retirement Medicare Premium Assistance Program (SLMB/QMB) E. SETTLOR (Person establishing Trust) The proposed Settlor should attend the initial consult. Only a parent, grandparent, guardian, court, or the beneficiary may establish a special needs trust. We will discuss in more detail during the consultation. Is Beneficiary competent? Yes No Does Beneficiary wish to establish trust? Yes No Does Beneficiary have a living parent or grandparent? Yes No Living Parent/Grandparent s Full Name Address City State Zip County Phone No. Does Beneficiary have a Guardian (Attach Letters of Guardianship) Yes No County of Guardianship Case No. Guardianship Type Person Only Estate Only Person and Estate Guardian s Full Name Street Address City State Zip County Phone No. F. TRUSTEE (Person or entity administering Trust) The proposed Trustee may wish to attend the initial consult. The beneficiary may not be the trustee. The Settlor may elect to enter into a pooled trust that has a specified trustee in place. We will discuss in more detail during the consultation. Trustee s Full Name Street Address City State Zip County Phone No. 2

25 G. DOCUMENTS Please bring a copy or original of the following documents with you to the consultation, if applicable: Social Security card, Letters of Guardianship, Medicaid card (front and back), Medicare card, Private insurance card, Most recent Social Security award letter. If you know that you are coming in to set up a pooled trust, please also bring: One of the following: Original driver s license, Passport, State identification card, or Certified copy of birth certificate; and A copy of utility or credit card bill with current address. 3

26 Settlement Services Questionnaire

27 SETTLEMENT SERVICES QUESTIONNAIRE This form is important. Your accurate and complete responses will help us best serve you. A. INJURED PARTY S PERSONAL INFORMATION Full Name Birth Date Street Address City State Zip County Type of Residence (Private home or apt., group home, ICF-MR, etc.) Phone No. Driver License /State I.D. No. Social Security No. (copy of card required) U.S. Citizen Yes No B. INJURED PARTY S MEDICAL INFORMATION Type of Medicaid: ABD Medicaid Healthy Start Healthy Families Waiver : Type Other: Medicaid Case No. (copy of card required) County Medicaid Office Address Medicaid Caseworker Phone Fax Medicare Claim No. (copy of card required) Other Medical Insurance (copy of card required) Date of Accident or Injury (if any) Date Funds Received (if any) Nature of Disability C. INJURED PARTY S INCOME AND RESOURCES Employer Phone No.

28 Address Monthly Earned Income Gross Net Monthly SSI (provide recent award letter) Monthly SSDI (provide recent award letter) Monthly Child Disability Benefit (provide recent award letter) Social Security Office Address Social Security Caseworker Phone Fax Other income (child support, alimony, annuity payments, etc.) Has the INJURED PARTY received the following? Personal Injury Settlement Back Payment from Social Security Inheritance Accrual of Savings Other What is the value of the assets and where are they currently held? D. INJURED PARTY S OTHER BENEFITS Home Care Waiver I/O Waiver Level One Waiver PASSPORT Other Waiver Food Assistance Section 8 or Public Housing Veterans Benefits PERS STRS Railroad Retirement Medicare Premium Assistance Program (SLMB/QMB) E. FAMILY 1) If the injured party is under 18 years old, please complete the following: Mother of Injured Party Does the mother live with the injured party? Yes No Full Name Birth Date Street Address City State Zip County Hickman & Lowder Co., L.P.A. 2 Settlement Services Questionnaire

29 Phone No. . Social Security No. (copy of card required) Employer Phone No. Address Monthly Earned Income Gross Net Father of Injured Party Does the father live with the injured party? Yes No Full Name Birth Date Street Address City State Zip County Phone No. . Social Security No. (copy of card required) Employer Phone No. Address Monthly Earned Income Gross Net Siblings of Injured Party Name Date of Birth 2) If the injured party is 18 or older, please complete the following: Is INJURED PARTY competent? Yes No Is the INJURED PARTY married? Yes No Living Parent or Grandparent of Injured Party Living Parent or Grandparent s Full Name Hickman & Lowder Co., L.P.A. 3 Settlement Services Questionnaire

30 Address City State Zip County Phone No. Guardianship Does INJURED PARTY have a Guardian (Attach Letters of Guardianship) Yes No County of Guardianship Case No. Guardianship Type Person Only Estate Only Person and Estate Guardian s Full Name Street Address City State Zip County Phone No. 3) Please indicate below all public benefits received by anyone living in the same household as the injured party: Public Benefits Received by Other Household Members Name Date of Birth Benefits Received Please bring the following documents with you to the consultation: Original Driver license, passport, or state identification card Copy of birth certificate Social Security card Letters of Guardianship Medicaid card (front and back) Medicare card Private insurance card Most recent Social Security award letter Hickman & Lowder Co., L.P.A. 4 Settlement Services Questionnaire

31 Intake sheet for PI settlement

32 1. Discuss scope of services and fees. Settlement Services Intake Conference with PI Attorney Trust Services Litigation Services Draft Trust Participate in Mediation Handle MSA Assist with Settlement Obtain Approval from CMS Assist with Medicare Claims Serve as Trustee Assist with Medicaid Liens Assist with 3rd Party Insurance Claims Fee: 2. Discuss counseling session with plaintiff. Our Office PI Attorney s Office Trustee s Office Other After Trust is Signed 3. Complete Intake Form. Personal Information Litigation Information Trust Information 1

33 Intake info for minor settlements

34 CLIENT NAME DOB SSN DOI Injury Type Parent(s) Address(es) Guardian of Estate Guardian of Person SNT Trustee Address of Trustee PI Attorney Guardianship of Estate Minor Finalized Sent Rec d Document Bond Application (if applicable) Motion to Deposit in Lieu of (if applicable) Motion to Dispense with Bond (if applicable) Application to Appoint Guardian of Minor Next of Kin of Proposed Ward Addendum to Guardianship Application (check court rules) Waivers and Consents from Next of Kin Fiduciary s Acceptance Oath Documents generated by Filed on Naming Hearing scheduled for Rec d file-stamped copy on Rec d cert signed by Judge on Closed on Settlement of Minor s Claim Finalized Sent Rec d Document Application to Settle Minor s Claims Waivers and Consents from Next of Kin Affidavit (use court s form if unable to serve absent parent) Entry Approving Settlement of Minor s Claim Addendum to Minor Settlement (check specific court rules) Documents generated by Filed on Naming Hearing scheduled for Rec d file-stamped copy on Rec d cert signed by Judge on Closed on

35 SNT Finalized Sent Rec d Document Motion to Establish Special Needs Trust & JE Application to Appoint Trustee Entry Appointing Trustee Special Needs Trust Documents generated by Filed on Naming Hearing scheduled for Rec d file-stamped copy on Rec d cert signed by Judge on Closed on Other Items Req d From Rec d Document Itemized statement of fees/expenses/invoices from PI atty Narrative Statement from PI atty Copies of expert invoices from PI atty Medicaid Lien information (final not interim) Medical records authorization for Medicaid lien information Life Care Plan/Medical Records Copy of PI Attorney Fee Agreement Birth Certificate Motion to Deposit in Lieu of Bond & Entry (for GDN or SNT) and/or Bond Structure Documents/Insurance Company Rating Calendar court filings Who is paying our fees: SNT Personal Injury Attorney Other {In Summit County, need Form GM.4; see web site} {In Stark County, need Court cover sheet; see website} {In Lucas County, use online probate forms; see website} {In Erie County, use their specific forms; see website; include JE setting hrg and letters of appointment} Document2

36 Settlement / Public Benefits Questionnaire

37 Franklin J. Hickman Janet L. Lowder, CELA* Elena A. Lidrbauch Andrea Aycinena Lauren K. Hamilton Linda M. Gorczynski David S. Banas Judith C. Saltzman, Of Counsel PRIVILEGED AND CONFIDENTIAL 1300 E. 9th Street, Suite 1020 Cleveland, OH Telephone (216) Fax (216) DELIVERY VIA: TO: FROM: DATE: RE: Settlement & Public Benefits Questionnaire The information requested below is necessary to determine whether a Special Needs Trust (Medicaid Payback Trust), or a Medicare Set-Aside Allocation is advisable, and to help identify any other issues such as Medicaid/Medicare liens which impact settlement planning. Please answer the questions below with the injured party s information and return to me. Indicate any sections that do not apply with a N/A. Please contact me should you have any questions. PERSONAL INFORMATION Name Date of Birth 1 Social Security No. 2 Date of Injury Type of Injury 3 Address Phone Number SETTLEMENT OR AWARD Gross Amount Subrogation liens and claims 4 Attorney Fees Suit Expenses Other Claims (Loss of consortium, etc.) Net Amount to Plaintiff Amount of Lump Sum Amount Structured Court where litigation was filed, or if not filed, name of party paying settlement Judge Case Caption Case Number 1 ATTACH COPY OF BIRTH CERTIFICATE IF A MINOR 2 ATTACH COPY OF CARD 3 ATTACH LIFE CARE PLAN OR DISCHARGE SUMMARY 4 INCLUDING MEDICARE, MEDICAID AND PRIVATE INSURANCE LIENS *Certified Elder Law Attorney By the National Elder Law Foundation Offices in Cuyahoga and Lorain Counties

38 GUARDIANSHIP/CONSERVATORSHIP Guardian/Conservator 5 Phone No. Address County Name of Judge/Magistrate Date Appointed Guardian/Conservator Type (Person, Estate, Limited, etc.) PRIVATE HEALTH INSURANCE Company Name 2 Policy No. Name of Policy Holder COBRA? Employment Related? Do you have private long-term disability insurance? If yes, how much do you receive? MEDICAID INFORMATION Medicaid Case No. 2 Medicaid Recipient No. If you are not currently receiving Medicaid, do you anticipate needing Medicaid in the future? If so, when? Do you need or expect to need constant care? Who provides that now? Are you receiving any other means-tested benefits (food assistance, TANF, Section 8, etc.)? MEDICARE INFORMATION Medicare Claim No. 2 (with letter) Effective date for Parts A and/or B If you are not currently receiving Medicare, do you anticipate qualifying for Medicare in the future? If so, will that occur in the next 30 months? SOCIAL SECURITY DISABILITY INSURANCE (SSD/SSDI) Date when SSD began Monthly award amount Date and status of SSD application If you are not currently receiving SSD, do you anticipate applying for SSD in the future? If so, when? Eligible for Medicare? SUPPLEMENTAL SECURITY INCOME (SSI) Date when SSI began Monthly award amount Date and status of SSI application If you are not currently receiving SSI, do you anticipate needing SSI in the future? If so, when? 5 ATTACH COPY OF LETTER OF GUARDIANSHIP ISSUED BY PROBATE COURT

39 WORKERS COMPENSATION (WC) Claim No. Employer s Name Employer s Address Employer s Phone No. Employer s Attorney s Name Employer s Attorney s Address Employer s Attorney s Phone No. WC carrier or excess insurance carrier s name WC Carrier s Address WC Carrier s Phone No. Name and Contact Information for attorney representing WC Carrier Proposed Settlement Date Gross Proposed Settlement Predetermined Allocations (Medical, attorney fees, wages) Amount of Lump Sum Amount Structured Amount of Current Periodic WC Payments Frequency of WC Payments Are the WC Payments labeled Temporary Total Disability (TTD), Permanent Partial Disability (PPD) or Permanent Total Disability (PTD)? What was the annual salary or hourly wage prior to the injury? Have you notified the Social Security Administration about your WC payments? SPECIAL NEEDS TRUST Does beneficiary/claimant have a parent, grandparent or legal guardian living? If yes, their full name If yes, their full address Name of proposed trustee Address of proposed trustee Phone Number of proposed trustee Relationship to beneficiary/claimant Name and relationship of all remainder beneficiaries after Medicaid payback Name, address, and age of all immediate family members and/or household members. If any person receives government benefits, note the type of benefit and monthly amount received Note: This is not an exhaustive list and provides the preliminary information to assist in determining whether a Special Needs Trust (Medicaid Payback Trust) or a Medicare Set-Aside Allocation is advisable, and to help identify any other issues such as Medicaid/Medicare liens which impact settlement planning. This is for general information purposes only and should not be construed as legal advice. \\SVRPDC\Office\FORMS\SNT\Settlement & Public Benefits Questionnaire.doc

40 Estate Planning Questionnaire (

41 Confidential Information Form - Estate Planning Date: Personal Data About You Name Home Address (street, city state and zip) Home Phone Work Phone Occupation Approximate Income Per Year Are you now or have you ever been self-employed? Yes No Date of Birth Place of Birth US Citizen? Yes No Address Personal Data Your Spouse / Partner Name Home Address (street, city state and zip) Home Phone Work Phone Occupation Approximate Income Per Year Are you now or have you ever been self-employed? Yes No Date of Birth Place of Birth US Citizen? Yes No Address Page 1 of 9 CONFIDENTIAL INFORMATION FORM -- ESTATE PLANNING

42 Children - of both of you Name (First, MI, Last), Address & Phone Birth Date Spouse Children (Names and Ages) Your Children Name (First, MI, Last), Address & Phone Birth Date Spouse Children (Names and Ages) Your Spouse / Partner s Children Name (First, MI, Last), Address & Phone Birth Date Spouse Children (Names and Ages) Miscellaneous Family Details Are You Legally Married? Date of Marriage Do you have a pre or post nuptial agreement? Yes No Yes No Page 2 of 9 CLIENT INFORMATION FORM -- ESTATE PLANNING

43 (Divorces, adoptions, disabilities): Other Dependents: (e.g., Parents) Name, Age, and Relationship Do you or your spouse/ partner have children by a previous marriage, or have children who died leaving children? Does anyone to whom you may be leaving part of your estate require any help or protection managing money or property? Is anyone in your family disabled, receiving public benefits or about to receive public benefits? Life Insurance Name of Company Policy No. Owner Primary Beneficiary Contingent Beneficiary Value: Death benefit + cash value Real Estate Owned Address or Location Title in Name of Date Acquired Original Purchase Price Current Mortgage Balance Current Value Time Shares Address or Location Title in Name of Date Acquired Original Purchase Price Current Loan Balance Current Value Page 3 of 9 CLIENT INFORMATION FORM -- ESTATE PLANNING

44 Retirement Benefits - IRA Name of Company or Plan Primary Beneficiary(ies) Account Balance or Expected Benefit Stocks and Bonds - Marketable Stocks, Bonds, and Mutual Funds (Attach separate schedule if necessary) (Not IRAs) Publicly Traded Name of Issuer (Company or Gov't Entity) Owner Basis for Computing Capital Gain or Loss Value Have you made any loans? Name of Debtor Original Amount Date Date Due Interest Rate Current Balance Bank Accounts Personal Checking, Savings, Certificate of Deposits, etc. Name of Bank Last 4 Digits of Account No Title - How Held Average Balance Page 4 of 9 CLIENT INFORMATION FORM -- ESTATE PLANNING

45 Closely Held Business Interests Name of Company Organization (LLC, Sub-S Corp, FLP, etc.) No. of Shares or percent of ownership Owner Shares Outstanding Operating Agreement Cost or Buy-Sell Agreement Other Basis Employment Contract SUBMIT COPY Business Interests (Partnerships, LLC s, Sole Proprietorships, Tax Shelters) Name of Entity Owner Date Cost or Other Basis Operating Agreement Buy-Sell Agreement Employment Contract SUBMIT COPY Other Deferred Compensation Plans (Including Qualified and Non- Qualified Options) Name of Company or Plan Primary Beneficiary Account Balance or Expected Benefit Percent Vested Method of Payment Benefits Tangible Personal Property (including automobiles, jewelry, furs, art objects, gun and coin collections, etc. include assets with value over 10,000.00) Item Owner Date Acquired Cost or Other Basis Fair Market Value Page 5 of 9 CLIENT INFORMATION FORM -- ESTATE PLANNING

46 Inheritances Are any inheritances likely to be received by either you or your spouse in the future? Debts - Estimated current liabilities excluding mortgages on real estate interests. Provide following detail as to any such liabilities in excess of 10,000: Amount of Debt Description of Collateral Security Name of Creditor Manner of Payment (e.g. demand installment, open, line credit) Gifts Made in Excess of 10, Year Description of Item Donee Cost or Other Basis Gift Tax Return Filed Value Are you or your spouse an agent, trustee, guardian or personal representative? Who Should Be Guardian(s) for Your Dependents? - + You have the authority to name a person to act as guardian for any minor or incapacitated child, or an incapacitated spouse or family member. Would you like to provide for such a person in your will? Name Address Relationship Page 6 of 9 CLIENT INFORMATION FORM -- ESTATE PLANNING

47 Who Should Make Financial Decisions for You? - + You will need to name a personal representative (executor), an agent for your power of attorney and possibly other persons to handle your finances if you are unable to do handle them yourself. Whom would you like to name for those roles? Name Address Relationship Who Should Make Health Care Decisions for You? - + Finally, you will need to name a person or persons to handle health care questions if you are unable to make decisions yourself. Whom would you like to name to that position? Name Address Relationship Age(s) of Distribution of Trust for Children At what age or ages after the deaths of you (and, if applicable, your spouse) do you think your children should receive substantial assets (in addition to distributions to properly provide for their care, support and education)? Special Terms of Trust for Children Specific Bequests Item Description Person Receiving Bequest Relationship Page 7 of 9 CLIENT INFORMATION FORM -- ESTATE PLANNING

48 Special Estate Planning Objectives and Other Legal Concerns Describe any special estate planning objectives or other legal concerns you may have: Advisors Name Address Telephone Attorney (Estate Planning) Fleming & Curti, P.L.C. 330 N. Granada Avenue Tuscon, AZ (520) Accountant Financial Advisor Life Insurance Agent Stock Broker Personal Fleming & Curti, P.L.C. Confidential and Privileged Information Does Fleming & Curti have permission to contact the Advisors that you have listed with any questions about your estate plans? Who referred you to us? Who referred you to us? May we thank him/her/them for the referral? Yes Yes No No Page 8 of 9 CLIENT INFORMATION FORM -- ESTATE PLANNING

49 Please bring the following documents with you to your meeting with the attorney: 1. Will, codicil, trust agreements 2. Life insurance and annuity policies and beneficiary designation forms 3. Statements of account for savings and checking accounts 4. Brokerage statements for stocks, bonds, and securities or copies of certificates and bonds 5. Guardianship documents, if applicable 6. Living will, advance directive, power of attorney, durable power of attorney 7. Employee or retiree benefit statements (beneficiary designations on IRA's, Keoghs, or other retirement plan), including current beneficiary designation 8. Business papers: operating agreement, partnership agreement, corporate minute books, buy/sell agreements Page 9 of 9 CLIENT INFORMATION FORM -- ESTATE PLANNING

50 Government Benefits Questionnaire

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59 Settlement Questionnaire for PI Lawyers

60 Re: Settlement approval Dear Personal Injury Attorney: I understand you have reached a settlement in your pending personal injury matter, and that approval of the settlement through the probate court will be required. We appreciate your assistance in familiarizing us with the underlying action by filling out the questionnaire contained in this letter. Most of this information will be required by the court. Typically, the probate court looks to the personal injury firm to absorb the cost for a minor's settlement approval and not to pass this cost on to the injured party s estate. Unless you instruct us otherwise, we will inform the court that you will be responsible for our fee and costs. We anticipate that our fee will be a flat (plus costs) in this case; once we have reviewed the information you provide us more closely, we will set a final fee. We would, of course, be happy to discuss the fee arrangement further. There have been many recent changes in both the practice and nature of the court regarding personal injury and wrongful settlements involving minors or incapacitated persons. Therefore, we would greatly appreciate you answering all of the following questions and providing us with all requesting documentation so we can properly represent the clients in this matter. All Plaintiffs names and dates of birth ( ), ( ), ( ), ( ). Do you represent each plaintiff? Y/N (If the answer is no, what other attorneys are involved?) If there are multiple plaintiffs, has the issue of allocation of settlement proceeds been addressed? Y/N If yes, how?

61 Page 2 Briefly describe each plaintiff s injury. Have you engaged a life-care planner? Y/N If yes, who? (phone number). What public benefits are received by which plaintiffs? plaintiffs family members? (benefit) (plaintiff) (benefit) (plaintiff) (benefit) (plaintiff) (benefit) (other) (benefit) (other) Is the ward/minor presently receiving Medicare? Previously received Medicare? Do you anticipate the ward/minor receiving Medicare within the next two years? Medicare is generally available two years after a person is determined to be eligible for Social Security Disability. Please provide the name and phone number of the ward/minor s ongoing treating physician. Social Security Nos. for ward or minors: If we are dealing with minors, and, if minors parents are not listed above already, please list names/address/social security numbers of each minor s parents and designate which parent(s) the minor(s) are residing.

62 Page 3 Does any plaintiff now have a court-appointed guardian or conservator? If so, please specify: Whom do you anticipate will be nominated as the conservator:, phone number (NOTE: If the Conservator lacks sufficient assets and/or income she/he may not be able to qualify for a bond. In this case either the assets will have to be restricted so that no withdrawals may be made without court approval or another person will have to be appointed to act as Conservator who is able to qualify for a bond. If the Conservator intends to charge for their services they must be certified as a Private Fiduciary through the Arizona Supreme Court.) All defendants participating in the settlement and their insurance companies:, insured by ;, insured by. Any Defendants not participating in this settlement: insured by. Please name Defendants counsel: Gross amount of settlement:. Your fee: ; Your costs:. Please provide us with a copy of the contingency fee agreement as well as any agreements to split fees with any other counsel (including referral fee agreements). If you expect to reduce your fee, please give us some indication of your current thinking in that regard. Date by which you will have an affidavit regarding your fees and costs (an

63 Page 4 hourly/itemized breakdown) ready:. Liens against settlement: (amt) (lien-holder) (amt) (lien-holder) Have lien negotiations been completed? Do you anticipate any further reduction? How was the settlement reached? Mediation? Judicial settlement conference? The mediator or settlement judge was:. What are the settlement terms? Please provide us with a copy of the settlement agreement? Is a structured settlement part of the agreement or under consideration? Y/N Do you anticipate any hold-up on the structure purchase coming from any defendant? Y/N Did you speak with your client about structures vs. other investment possibilities? Y/N Is this settlement confidential? Is there a pending workers comp case?

64 Page 5 Please fax us this form as soon as you can. We will send a different questionnaire to the proposed conservator and will be meeting presently with that person. We look forward to working with you on this matter. Very truly yours, fleming@elder-law.com Robert B. Fleming Certified Specialist, Estates and Trusts

65 Guardianship / Conservatorship Questionnaire for Parents Signature

66 GUARDIANSHIP/CONSERVATORSHIP QUESTIONNAIRE To Prospective Client: In order for the firm of Fleming & Curti, P.L.C. to prepare a Petition for Appointment of a Guardian and/or Conservator please fill out the following Questionnaire as completely and accurately as possible. The person to be appointed as Guardian or Conservator must complete and sign this form. INFORMATION AS TO THE PERSON TO ACT AS GUARDIAN AND/OR CONSERVATOR OR IF NOT ACTING, INFO ON MINOR'S PARENTS Name Date of Birth Social Security Number Address: Home Phone Business Phone Name of Employer Address of Employer Spouses Name/Address/ph one Relationship to Proposed Ward

67 INFORMATION ON THE INCAPACITATED PERSON OR PERSON IN NEED OF PROTECTION (MINOR) Name: Date of Birth: Social Security Number: Name and Address of all parents of the minor: Is the minor or any other family member receiving benefits (SSI, SSD, ALTCS, AHCCCS)? Please provide us with a copy of the minor's birth certificate. The undersigned acknowledges that, in acting as a guardian or conservator, he/she owes a fiduciary duty to the ward. A guardian and conservator must invest and spend money in a manner that is in the best interests of the ward. A guardian or conservator cannot buy assets from a ward, borrow money from a ward or accept gifts from a ward without prior approval and order by the Court. A guardian and conservator must invest funds of the ward in a prudent manner; failure to do so can result in the guardian or conservator being personally liable for any loss. Fleming & Curti, P.L.C. recommends that an independent noncommissioned financial planner by retained by the guardian and conservator to review the ward's investments. The guardian and conservator must keep the Court advised of their addresses and the address of the ward. The conservator must keep the ward's assets separate from his or her own assets, and must do an annual written accounting of the ward's assets, income and expenses. A guardian must file an annual report, as well. If you have any questions contact Fleming & Curti, P.L.C. before taking any action. Signature of Guardian/Conservator: Printed name of Guardian/Conservator:

68 Dated: