Fill and Sign the Elder Law Attorneys Ampamp Medicaid Planning 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 financial business, who would you want to take care of your legal, business, personal, and financial 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 beneficiary have special educational, medical or physical needs, or receive governmental benefits? Yes No Does any potential beneficiary have any potential problems with drug or alcohol abuse? Yes No Are you concerned with any potential beneficiary’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