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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: _________________$________ Does Client have a long-term care insurance policy? Yes No If yes, please list the name of the provider and monthly premium: _________________$________ 1 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 2 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: 3 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 4 $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: _______________________________________________ 5 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? 6 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 7