Fill and Sign the Elder Law Form

Elder Law & Disability Planning Questionnaire Reason for visit (check all that apply): Estate Planning (Wills, Trusts, Healthcare Documents, Deeds) Guardianship Probate Elder Law Issues (Asset Protection, Medicaid/Medicare Planning, Other Related Issues) Client Spouse Name       Name       Address       Address       Home Phone       Home Phone       Cell Phone       Cell Phone       Email       Email       Birthdate       Birthdate       SSN       SSN       Have you or your spouse been married before ? Yes No If yes, do you or your spouse have any children from this previous marriage? Yes No Do you or your spouse have children who have died leaving children? Yes No Does anyone to whom you may be leaving part of your estate require any help or protection in managing money or other property? Yes No Do you and your spouse have a pre-nuptial or post-nuptial agreement? Yes No MEDICAL/DISABILITY Is anyone in your family disabled? Yes No If yes, please explain       Is anyone at risk for becoming seriously ill or disabled because of a medical condition or family history? Yes No If yes, please explain       Has anyone in your family recently entered a hospital or skilled nursing facility? Yes No If yes: Name of facility       Date of admission       Date of discharge       Diagnosis       Please describe client’s physical and mental condition       Please describe client’s spouse’s physical and mental condition       Do any other family members have a disability? Yes No If yes: Name and relationship       Describe the disability       Is either the client or the client’s spouse currently a patient of a nursing home, ALF or hospital? Yes No If yes: Nursing home patient       Name of nursing home, ALF or hospital Date of admission to the hospital       nursing home       ALF       Please provide any other information that you believe will be beneficial to the planning process:       What medical or health problems do you currently have?       What medical problems have you had in the past?       Please list all of the medications you are currently taking and why you are taking it:                                           Does your family have a history of health problems (for example, heart disease, cancer, or Alzheimer's disease)? Yes No If yes, describe       Mother’s age at death       Cause of death       Father’s age at death       Cause of death       Name of your persona1 physician(s): Name       Name       Address       : Address       : Phone       Phone       Email       : Email       : Specialty       : Specialty       : HEALTH AND LTC INSURANCE Client’s Medicare Number       Spouse's Medicare Number       Insurance from Employer       Medicare Supplement       Long-Term Care Insurance       Other       Activities of Daily Living ( Mark the box that best applies for each activity.) Activity Need No Help Need Some Help Unable to Do Without Help Bathing Dressing Transferring from bed to chair Walking Feeding self Using the toilet Grooming Public transport Using the telephone Grocery shopping Preparing meals Managing money Doing laundry Doing housework or handyman work Taking medications List the names(s) and address (es) of all person(s) or agency providing assistance or caregiving for you:                         Where do you live? Single-family home or townhome Apartment or retirement living community Assisted-living facility Nursing home : Other       Since When?       CHILDREN Children Name Address Phone Birthdate                                                                                                 Grandchildren Name Address Phone Birthdate                                                                                                 Are any of your children blind? Yes No Are any of your children disabled? Yes No Do any of your children live with you in your home? Yes No LEGAL DOCUMENTS Document State Where Executed Location of Original Date Executed Last Will and Testament                   Durable Power of Attorney                   Living Will/Health                   Care Proxy Living Trust                   Are you or your spouse the beneficiary of any trust? Yes No Do you or your spouse expect an inheritance? Yes No I am the legally appointed guardian of       I am serving as a power of attorney for       I am serving as executor or administrator of an estate. Yes No I am involved in a lawsuit or have reason to believe I will be involved in a lawsuit. Yes No If yes, describe       Other legal concerns       FINANCIAL INFORMATION Have you or your spouse made any uncompensated transfers or gifts to individuals or charities during the past five years? Yes No Have you, in the past 5 years, paid money for someone else's benefit (for example, paying for a child's wedding, paying for a grandchild's education, etc.)? Yes No Have you lost any money gambling in the past 5 years? Yes No Have you made any loans that are still outstanding (i.e., does anybody owe you money?) Yes No (Gifts made in excess of $1,000/year to an individual other than your spouse within the past 36 months): Recipient       Date       Amount       Consideration received       Recipient       Date       Amount       Consideration received       Has the client or the client’s spouse made any other person a joint owner of any asset(s)? Yes No If yes: Recipient       Date       Amount       Consideration received       Recipient       Date       Amount       Consideration received       Do you or your spouse expect an inheritance? Yes No Are you or your spouse the beneficiary of any trust? Yes No I have lived in a community property state (Arizona, Calif., Idaho, Louisiana, Nevada, New Mexico, Texas, Washington) Yes No Current Assets Current Liabilities Cash on Hand or in Banks       Notes Payable (Secured)(Schedule F)       Other Cash:       Notes Payable (Unsecured)(Schedule G)       Real Estate (other than residence Schedule A)       Real Estate Mortgages Payable (Schedule H)       Residence       Auto Loans (Schedule I)       Motor Vehicles (Schedule B)       Unpaid Taxes and Interest       US Government Securities (Schedule C)       Due to Brokers       Non-Marketable Securities (Schedule D)       Open Accounts       Stocks (Schedule E)       Credit Cards (List):       Other Personal Property                   Life Insurance Cash Value                   Business Interests                   Notes Receivable                   Other Assets: Other:                                                                                     Total Liabilities                               TOTAL OF ALL ASSETS                   LESS TOTAL OF ALL LIABILITIES       Total Assets       NET WORTH       Individual Income Information (Annual) Salary       Bonus       Commissions       Dividends       Rental Income       Other Income (List):                         Total Income       Contingent Liabilities Guarantor, Co-maker       Lease or Contracts       Legal Claims       Other:             SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired       $       $                   $       $                   $       $                   $       $                   $       $                   $       $             Total $       $       SCHEDULE “B” MOTOR VEHICLES Description of Motor Vehicles Cost Value       $       $             $       $             $       $             $       $             $       $             $       $       Total $       $       SCHEDULE “C” U.S. GOVERNMENT SECURITIES Description of Stock or Bond Date Acquired Par Value Market Value             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “D” NON MARKETABLE SECURITIES Description Date Acquired Par Value Market Value             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “E” STOCKS Company Shares Date Acquired Par Value Market Value                   $       $                         $       $                         $       $                         $       $                         $       $                         $       $                         $       $                         $       $       Total $       $       SCHEDULE “F” NOTES PAYABLE SECURED Description Date Balance Payment (m/yr)             $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “G” NOTES PAYABLE UNSECURED Description Date Balance Payment (m/yr)             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “H” REAL ESTATE MORTGAGES Description Date Balance Payment (m/yr)             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “I” AUTO LOANS Description Date Balance Payment (m/yr)             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       Do you or your spouse have an interest in any business? Yes No Describe       What is the private pay rate of the nursing home or assisted living facility (ALF) where the client or client’s spouse staying or will be staying? Daily       Monthly       List any other expenses that are anticipated at the nursing home or ALF       What is the monthly cost of Medicare Supplement Insurance for client?       For client’s spouse       If the client’s spouse is, or going to be, in a nursing home or ALF, how much income will be needed monthly to pay ongoing expenses of the well spouse?       LEGAL AND FINANCIAL DECISIONS If you were unable to carry out your legal and fnancial business, who would you want to take care of your legal, business, personal, and fnancial affairs? First Choice: Name       Address       Phone       Second Choice: Name       Address       Phone       If you were in the hospital and unable to make decisions for yourself, with whom would you want your doctor to consult with about your care (that is, to be your health care advocate)? First Choice: Name       Address       Phone       Second Choice: Name       Address       Phone       Does any potential benefciary have special educational, medical or physical needs, or receive governmental benefts? Yes No Does any potential benefciary have any potential problems with drug or alcohol abuse? Yes No Are you concerned with any potential benefciary’s ability to handle/manage money? Yes No Are you concerned with your children’s ability to get along with one another? Yes No Are their problems/concerns relative to your relationship with your children (or spouse’s children)? Yes No Have any of your children received a divorce? Yes No If possible, please bring copies of the following documents with you to your meeting with the attorney: Existing Durable Powers of Attorney Life insurance policies and annuities Income tax return for last year Deed(s)/Appraisals Current bank and brokerage account statements Existing Wills, Codicils, and Trust Agreements Admission Agreements to hospitals and health facilities Divorce Decrees, Prenuptial Agreements, Adoption Papers Guardianship documents Living Will, Health Care Declaration or Power of Attorney, Durable Powers of Attorney A list of full names, addresses, telephone numbers of people who have a part in your planning as executors, trustees, beneficiaries of your estate, helpers, and advisors Retirement plans, including any forms designating beneficiaries