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Mile High Estate Planning 1610 Wynkoop Street, Suite 550, Denver, CO 80202 (T) 720-924-6171 (F) 720-399-5560 (E) [email protected] www.MileHighEstatePlanning.com Personal Information Form Medicaid Applicant’s Information Full Legal Name Preferred Name Date of Birth Preferred Phone Email Address U.S. Citizen? If no, please specify Veteran? If yes, please specify branch and dates of service. Spouse’s Information Full Legal Name Preferred Name Date of Birth Preferred Phone Email Address U.S. Citizen? If no, please specify Veteran? If yes, please specify branch and dates of service. Couple’s Information Home Address Date of Marriage Did you sign a Pre- or Post- marriage contract? Mile High Estate Planning Page 1 of 7 Estate Planning Documents Check any that you have previously completed Husband Wife Will Trust Financial Power of Attorney Medical Power of Attorney HIPPA Release Pre-paid Funeral Arrangements Are you the beneficiary of any trust? (if yes, please specify) Children Full Name Gender Date of Birth Specify parent if not Married shared Does the Medicaid applicant have any minor, blind or disabled children living with them? Medicaid Planning Information Where does the applicant currently reside? Has the resident recently been hospitalized or in a rehabilitation program? If yes, please describe. Mile High Estate Planning Page 2 of 7 Please describe the current mental capacity of the applicant. Is the applicant currently receiving any VA pension or service-related disability benefits? Have any gifts of money or property been made over the past 5 years? If so please specify the value and recipient. Is anyone in the household currently on Medicaid? Has anyone in the household applied for Medicaid? What is the status? Is anyone in the household receiving Social Security? Asset Information Please specific the owner(s) of each asset. Include all assets currently held in trust; the Trustee of any trust will be the owner of any trust assets. Professional Advisors Name Company Accountant Financial Advisor Mortgage Holder Mile High Estate Planning Page 3 of 7 Real Estate Include all real estate interests including vacation homes, time shares and undeveloped land General Description and Address Note any property used for business purposes Market Value Loan Balance Owner Furniture and Personal Effects List major personal effects such as jewelry, collections, antiques, furs, and other valuables. For less valuable items give a lump sum value in the last line. Item / Description Market Value Miscellaneous Furniture and Household Effects Owner Lump sum Automobiles List each of your motorized vehicles, including cars, boats, and RVs Vehicle Type Make, Model, Year Market Value Encumbrances? specify amount) Owner Intellectual Property List trademarks, patents, registered designs, copyrights, or other intellectual property. Type Mile High Estate Planning Value Owner Page 4 of 7 Bank Accounts List all types of bank accounts including checking, savings, certificates of deposit, and money market accounts. Do not include IRAs or 401(k)s here. Note: If an account is in your name for the benefit of a minor, please provide minor’s name. Account Type Bank Name Balance Owner Money Owed To You List any mortgages or promissory notes payable to you or other moneys owed to you. Name of Debtor Date of Note Maturity Date Current Balance Owner Other Financial Accounts List all stocks, bonds and investment accounts, as well as pension, profit sharing, H.R.10, IRA, SEP, and 401(k) plans. If held in a brokerage account, lump together on one line. Type Financial Institution Account No. / Plan Name Balance Owner Who are the designated beneficiaries of your retirement accounts and IRAs? Primary Mile High Estate Planning Secondary Page 5 of 7 Life Insurance, Annuities, Long Term Care Insurance List any type of life insurance policy such as term, whole, group, split dollar or annuity. Please also include any long term care insurance. Policy Owner Policy Type Insurance Co and Agent Face Value Death Benefit Premium Payer Beneficiaries Business Interests List any businesses such as general or limited partnerships, sole proprietorships, privately owned corporations, professional corporations, oil interests, and farm and ranch interests. Business Name and Type Business’ Market Value Owner Percent Owned Do you have a buy-sell agreement? Anticipated Moneys List any expected gifts or inheritances, and any money you expect from a lawsuit. Source of Money or Property When Will You Receive It? Specify Recipient Value or Amount Are you currently being sued? If yes, please attach an explanation. Mile High Estate Planning Page 6 of 7 Other Assets List any other property you have that does not fit into the above categories. Item / Description Value Owner How did you hear about Mile High Estate Planning? ___Google ___Radio Adds ___Other, Please Specify ___________________________ Thank you for taking the time to provide this information so that we are able to provide you with the best service. Please contact MHEP if you have any questions. Mile High Estate Planning Page 7 of 7