LONG TERM CARE
PLANNING QUESTIONNAIRE

Your information is secure and kept confidential.
 
This questionnaire is intended to elicit preliminary information necessary to help us with estate and benefits planning pertinent to your particular circumstances. The more complete and accurate your responses, the better we will be able to serve you.

It would be very helpful if you would send us the completed form before our initial consultation. Please contact our office at 1-828-669-0799 if you have any questions about this form or need assistance completing the requested information.
 
BIOGRAPHICAL INFORMATION
   
Today's Date

Name
(person for whom benefits are sought)
Date of Birth
  Social Security Number
Street Address
City
State
Zip
County of Residence
Day Phone
Evening Phone
Email Address
U.S. Citizen Yes No
If no, citizen of
Employer
Retirement Date
Veteran Yes No
Branch of Service
Years of Service
Service Connected Disability? Yes No
Spouse
Date of Birth
Social Security Number
US Citizen Yes No
If no, citizen of
Employer
Retirement Date
Veteran Yes No
Branch of Service
Years of Service
Service Connected Disability? Yes No
If spouse is deceased, date of death
 
   FAMILY
     
  Date of Marriage
  Number of Children
 
Name
 
Age
 
Address
Telephone
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 

 Names and Ages of Grandchildren

Name
Age
Are any of your children blind, or
disabled, or receiving SSI benefits?

Yes No
     
Is anyone (other than your spouse) dependent upon you for support?
Yes No
     
Have your or your spouse been
married before?
Yes No
     
If yes, do you or your spouse have any children from a 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
     
Have any of your children or brothers or sisters lived with you during the last two years?
Yes No
     
 MEDICAL/DISABILITY
     
Are you or your spouse blind, disabled or receiving SSI? Yes No
   
If yes, please explain
     
Are you or your spouse at risk for becoming seriously ill or disabled because of a medical condition or family history?
Yes No
   
If yes, please explain
Your Doctor
Spouse's Doctor
     
Have you or your spouse recently entered a hospital or skilled nursing facility? Yes No
   
Name of facility
   
Level of Care ICF SNF Rest Home
       
Date of Admission        
   
Date of Discharge        
   
Diagnosis
     
Have you or your spouse previously been in the hospital or nursing home for a combined stay of 30 days or more since September 30, 1989? Yes No
   
If yes, please explain giving dates and name of facility
 
HEALTH INSURANCE
   
Your Medicare Number
Spouse's Medicare Number
Insurance from Employer
Medicare Supplement
Long-Term Care Insurance
Other
 
MONTHLY INCOME
     
You
Your Spouse
Joint
Social Security
Employment
VA Benefits
Private Pension
IRAs, Annuities, etc
Rents
Business Interest
Regular Support from Others
Trust Income
Total Monthly Income
Which sources of income have a benefit
for a surviving spouse?
 
 
MONTHLY EXPENSES
 
MONTHLY SHELTER EXPENSES
Rent/Mortgage
Home Equity Loan
Real Estate Taxes
Water
Sewer
Utilities (heat, electric, phone)
Home Owners' Insurance
Condominium Fees
Total Monthly Shelter Expenses
 
MONTHLY NON-SHELTER EXPENSES
   
Food
Medical
Clothing
Transportation
(including auto insurance)
Home Maintenance
Life Insurance Premiums
Health Insurance Premiums
Cable T.V.
Federal and State income taxes
Other
Total Monthly Non-Shelter Expenses

     MONTHLY NURSING HOME EXPENSE
   
Monthly Nursing Home Cost
Monthly Prescription Cost
Monthly Incontinent Cost
Monthly Other Cost
Total Monthly Nursing Home
Expenses

The nursing home is paid through
   
 
ASSETS

INVESTMENTS AND SAVINGS
 
(checking accounts, savings accounts, money market accounts, certificates of deposit, IRA's)
       
Financial Institution
Account Number
Value
In Whose Name
     
 
Total : 
 
STOCKS AND BONDS
       
Issuer/Broker
Account Number
Value
In Whose Name
     
 
Total : 
       
RETIREMENT ACCOUNTS
 
Company and Type
Current Value
In Whose Name
Beneficiary
 
 
     
 
Total : 

PREPAID FUNERAL OR BURIAL ARRANGEMENTS
       
   Description
(revocable, irrev., trust acct.)
In Whose Name
Current Value
 
REAL ESTATE
       
Purchase Date
Purchase Price
Tax Value
In Whose Name
   
Please describe (outstanding debt, to whom
owed, etc.) any mortgage or deed of trust to
which any of these properties may be subject.

LIFE INSURANCE
Whose Life
Company
Policy Number
Face Value
Cash Value
Beneficiary
 
    
  Please describe any loans on these insurance policies
 
 
Description
Current Balance
Monthly Payment
Maturity Date
 
 
   
   Other Assets
         
 
Type of Asset
Where asset is located
Value
In Whose Name
 
 
   
Do you or your spouse have an interest in
any business?
Yes         No
   
  If yes, please describe
     
PERSONAL PROPERTY
 
   (autos [licensed & unlicensed], RVs, boats, antiques, heirlooms, jewelry, collections, farming    equipment, etc.)
     
Description
Value
In Whose Name
     
       LIABILITIES
 
(mortgages, notes to banks, notes to others, not listed above)
 
Description
Current Balance
Monthly Payment
Maturity Date
       
     OTHER LIABILITIES
       
Type of Liability
Current Balance
Monthly Payment
Maturity Date
 
   TRANSFERS
 
   Have you or your spouse made any transfers or gifts of more than
   $4,200 during  the past five years?


Yes        No
   LEGAL
     
Date
Executed
State Where
Executed
Location of
Original
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
   
  Other legal concerns
 
EXPRESS WAIVER OF CONFIDENTIALITY
 
All communications between the client and Wendy A. Craig, P.A. are confidential and will not be disclosed to anyone without the client's express written consent. However, the client (if the client is the party completing this questionnaire) may waive his or her right to confidentiality and authorize this firm to discuss his or her affairs and provide information and documentation to the persons or organizations designated below:

Family Members

Advisors (accountants, brokers, insurance agents, etc.)

 
BY WHOM WERE YOU REFERRED TO THIS OFFICE?
   
Name
Street Address
           
     City 
State 
Zip 
 
CERTIFICATION

By submitting this form, you hereby represent to the Wendy A. Craig, P.A., that the information contained in this intake form is accurate and complete, and that you understand that the law firm and its individual lawyers will rely on this information. If the information contained herein is inaccurate or incomplete, the recommendations made by the law firm may not be appropriate.
 
CLIENT IDENTIFICATION
 
Please note that our office most often regards the person for whom benefits are sought as our client. In certain circumstances, we may also represent spouses. If you are not the client, please provide your name, address and relationship to the client.

Name
Street Address
City
State
Zip
Email
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Please print a copy of the completed Questionnaire for your files before e-mailing the same to our office. (Once you e-mail the form to our office, the form will "clear" the information you have typed in and you will not be able to print a completed copy.)


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