Download elder care planning questionnaire

ELDER LAW PLANNING QUESTIONNAIRE
(UNMARRIED)
The information that you provide in this questionnaire is extremely important.
Your accuracy and completeness in your responses is necessary to allow me to
assess your situation. No attorney-client relationship has been formed by
completing this questionnaire. However, all information provided is strictly
confidential.
If you have any questions, please do not hesitate to contact our office at (412)
772-1925. Take your time and answer all of the questions to the best of your
ability.
ELDER LAW PLANNING QUESTIONNAIRE
CONTACT INFORMATION (if other than Client)
Name _____________________________________ Telephone Number _________________________
Address_________________________________________________________________________
City ___________________________County ___________________ State ________ Zip____________
Email _____________________________________ Relationship to Client _______________________
PERSONAL DATA
Client:
Full Name _______________________________ Address_____________________________________
Birth Date _______________________________ City ___________________________ State ________
Social Security No. ________________________ County ______________________ Zip____________
U.S. Citizen? Yes
No
Email ______________________________________
Veteran?
Yes
No
If yes, date of discharge: _________________ Telephone Number ____________________________
If widowed, please list name of spouse and date of death _______________________________________
Was your former spouse a veteran? Yes
No
MEDICAL INFORMATION: PHYSICIANS
Full Name of Client’s Primary Physician __________________________________________________
Street Address _______________________________________________________________________
City ___________________________County________________ State __________ Zip __________ __
Telephone Number: _________________________ Health of Client _____________________________
MEDICAL INFORMATION: INSURANCE
Health Insurance Provider_______________________________ Policy Number/ID_____________________
Is Client currently receiving benefits under PACE or PACENET?
If Client is a Veteran, are they receiving Tricare?
Yes
No
Yes
No
Does Client have a supplemental health insurance policy?
Yes No
If yes, please list the name of the provider and monthly premium: _________________$________
Does Client have a long-term care insurance policy?
Yes No
If yes, please list the name of the provider and monthly premium: _________________$________
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MEDICAL INFORMATION: LONG TERM CARE
If client is or contemplates entering a nursing home, please provide the following:
Medical Condition _____________________________________________________________________
Prognosis ___________________________
Type of care:
Nursing Home
Course of Treatment ____________________________
Assisted Living
Personal Care
Home Care
None yet
If client is Ill and currently a resident of an assisted living facility or nursing home, please provide
the following:
Name of Facility ______________________________________________________________________
Facility Address _______________________________________________________________________
City_______________________ County_______________________ State___________ Zip _________
Monthly Cost of Nursing Home Care, If Applicable
Facility Cost
Prescription Cost
Incontinent Cost
Caregiver Cost
Other
Other
Total Monthly Cost
$__________________
$_________________
$_________________
$_________________
$__________________
$__________________
$__________________
Medicare coverage ended/will end: _____________________
Month
Day
Year
The facility is paid through: _______________________
Month
Day
Year
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FINANCIAL INFORMATION
Please use approximate values when completing the following worksheet.
ASSETS
CLIENT
JOINT
Personal Effects
Automobiles
Residence
Purchase Price:
Other Real Estate
Checking Accounts
Savings Accounts
Money Market Accounts
Certificates Of Deposit
Investment Accounts
Stocks/Bonds/Mutual Funds
U.S. Savings Bonds
Annuities
IRA and Retirement Plans
Business Interests
Prepaid Funeral
Burial Plot
Other:
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NAME OF JOINT
OWNER
LIABILITIES
LIFE INSURANCE
Type
Owner/Insured
Company __________
Policy #____________
term
whole
Company___________
Policy # ___________
term
whole
Company___________
Policy ____________
term
whole
Company___________
Policy # ___________
term
whole
Beneficiary
MONTHLY INCOME
Type
Salary/Wages
Social Security Benefits
Pension
Retirement Benefits (Gross)
Veterans Disability Income
Disability
Annuity Income
Interest/Dividends
Rental Income
Other Income
Medicare Part D
Medicare Part B Deduction
Face Amount
Death Benefit
Amount
$94.60
$134.90
$192.70
MONTHLY SHELTER EXPENSES
Mortgage
Rent
Real Estate Taxes
Water
Sewer
Gas
Electric
Telephone
Homeowner’s/Renter’s Insurance
Condominium Fees
MONTHLY NON-SHELTER EXPENSES
Food
Health Insurance Premiums
Dental Insurance Premiums
Vision Insurance Premiums
Clothing
Automobile Insurance Premiums
Home Maintenance
Life Insurance Premiums
Federal and State Income Taxes
Cable TV
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$250.50
$308.30
$_____
Cash Value
OTHER RECURRING EXPENSES (NOT NOTED ABOVE)
GIFTS
Have you: 1) made gifts in excess of $500 in any one month to an individual(s); 2) transferred assets to an
individual(s) or to a trust within the past 60 months; or 3) added or removed their name(s) from any bank,
investment or financial accounts held jointly with another individual?
If yes, list below:
Recipient ____________________________
Date _____________
Amount ____________
Recipient ____________________________
Date _____________
Amount ____________
Recipient ____________________________
Date _____________
Amount ____________
Recipient ____________________________
Date _____________
Amount ____________
Have you ever filed a Federal Gift Tax Return? Yes
No
If so, for what calendar year(s)? ____________________________________
CURRENT ESTATE PLAN
CLIENT – Do you have any of the following estate planning documents?
Last Will & Testament?
Yes
No
Financial/General Durable Power of Attorney? Yes
No
If yes, Agent: ________________________
Healthcare Power of Attorney/Living Will?
No
If yes, Agent: _______________________
Trusts? Yes
No
Yes
If yes, name of Trust: _______________________________________________
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CHILDREN (if applicable, including adult children)
Check this box if you have no living children
Name of Child ______________________________________________________________________
Street Address _________________________________________________________________
City _________________________
State _________________
Zip _______________
Phone Number ________________
E-mail ________________________________
Date of Birth __________________
Marital Status ___________ Children __________________
Name of Child _______________________________________________________________________
Street Address _________________________________________________________________
City _________________________
State _________________
Zip _______________
Phone Number ________________
E-mail ________________________________
Date of Birth __________________
Marital Status ___________ Children __________________
Name of Child _______________________________________________________________________
Street Address _________________________________________________________________
City _________________________
State _________________
Zip _______________
Phone Number ________________
E-mail ________________________________
Date of Birth __________________
Marital Status ___________ Children __________________
Name of Child _______________________________________________________________________
Street Address _________________________________________________________________
City _________________________
State _________________
Zip _______________
Phone Number ________________
E-mail ________________________________
Date of Birth __________________
Marital Status ___________ Children __________________
Name of Child _______________________________________________________________________
Street Address _________________________________________________________________
City _________________________
State _________________
Zip _______________
Phone Number ________________
E-mail ________________________________
Date of Birth __________________
Marital Status ___________ Children __________________
Does any child live at home?
Are any of your children disabled?
Do any of your children have marital difficulty?
Does any child provide care for Client?
Yes
Yes
Yes
Yes
No
No
No
No
If yes, please name. _______________
If yes, please name. _______________
If yes, please name. _______________
If yes, please name. _______________
Are any of your children receiving government benefits such as Social Security Disability, SSI, Medicaid
or Veteran’s Benefits? Yes No If yes, please specify. _____________________________________
Do any of your family members have any problems with: Drug Addiction?
Alcoholism?
Spendthrift?
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Yes
Yes
Yes
No
No
No
MISCELLANEOUS
Do you have a Safe Deposit Box?
Yes No
If yes, please provide name of bank and where it is located: ____________________________________
Do you own a firearm?
Yes No
If yes, where is it located? _____________________________________
YOUR ADVISORS:
Name
Phone Number
Accountant
_________________________
_________________________
Life Insurance Agent
_________________________
_________________________
Investment Advisor
_________________________
_________________________
Other Attorney
_________________________
_________________________
NOTES/COMMENTS: ______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
CERTIFICATION
The undersigned hereby represents to Maureen P. Gluntz, Attorney at Law, that the information contained in
this Elder Law Planning Questionnaire is accurate and complete, and that the undersigned understands that
Maureen P. Gluntz and her staff will rely on this information. We understand that if the information contained
herein is inaccurate or incomplete, the recommendations made by Maureen P. Gluntz may not be appropriate.
Signatures:
Date: _________________________
_____________________________________
Client
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