Long-Term Care Planning Questionnaire - J. L. Williamson Law Group

SECTION 3: CHILDREN

Total Number of Children:

Please enter a number from 0 to 6.

Child 1

Name of Child 1

First Middle Last Suffix

Date of Birth of Child 1

Parent of Child 1:

Client
Spouse
Both

Child 1 Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child 1 Phone Number

Is child 1 adopted?

Yes
No

Child 1 Date of Adoption

Court Granting Adoption of Child 1

Is child 1 deceased?

Yes
No

Child 1 Date of Death

Does child 1 have surviving children?

Yes
No

Describe Child 1. Does he or she have "special needs"?

Child 2

Name of Child 2

First Middle Last Suffix

Date of Birth of Child 2

Parent of Child 2:

Client
Spouse
Both

Child 2 Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child 2 Phone Number

Is child 2 adopted?

Yes
No

Child 2 Date of Adoption

Court Granting Adoption of Child 2

Is child 2 deceased?

Yes
No

Child 2 Date of Death

Does child 2 have surviving children?

Yes
No

Describe Child 2. Does he or she have "special needs"?

Child 3

Name of Child 3

First Middle Last Suffix

Date of Birth of Child 3

Parent of Child 3:

Client
Spouse
Both

Child 3 Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child 3 Phone Number

Is child 3 adopted?

Yes
No

Child 3 Date of Adoption

Court Granting Adoption of Child 3

Is child 3 deceased?

Yes
No

Child 3 Date of Death

Does child 3 have surviving children?

Yes
No

Describe Child 3. Does he or she have "special needs"?

Child 4

Name of Child 4

First Middle Last Suffix

Date of Birth of Child 4

Parent of Child 4:

Client
Spouse
Both

Child 4 Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child 4 Phone Number

Is child 4 adopted?

Yes
No

Child 4 Date of Adoption

Court Granting Adoption of Child 4

Is child 4 deceased?

Yes
No

Child 4 Date of Death

Does child 4 have surviving children?

Yes
No

Describe Child 4. Does he or she have "special needs"?

Child 5

Name of Child 5

First Middle Last Suffix

Date of Birth of Child 5

Parent of Child 5:

Client
Spouse
Both

Child 5 Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child 5 Phone Number

Is child 5 adopted?

Yes
No

Child 5 Date of Adoption

Court Granting Adoption of Child 5

Is child 5 deceased?

Yes
No

Child 5 Date of Death

Does child 5 have surviving children?

Yes
No

Describe Child 5. Does he or she have "special needs"?

Child 6

Name of Child 6

First Middle Last Suffix

Date of Birth of Child 6

Parent of Child 6:

Client
Spouse
Both

Child 6 Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child 6 Phone Number

Is child 6 adopted?

Yes
No

Child 6 Date of Adoption

Court Granting Adoption of Child 6

Is child 6 deceased?

Yes
No

Child 6 Date of Death

Does child 6 have surviving children?

Yes
No

Describe Child 6. Does he or she have "special needs"?

Name of Bank/Branch	Account No.	Type of Account	Balance/Value	How Title Held

Name of Company	Type of Sec.	# Shares/Face Val.	Cost	Current Val.	How Title Held

Name of Institution	Account No.	Owner	Beneficiary	Date Established	Current Value

Description (Location)	Cost (Basis)	Market Value	Mortgage Balance	How Title Held

Name of Insurer	Policy No.	Type of Policy	Monthly Premium ($)	If LTC, Daily Benefit ($)

Additional Client Document	Additional Spouse Document

Recipient	Amount/Value of Gift	Date of Gift

Recipient	Amount/Value of Gift	Date of Gift

Name of Trust	Amount/Value of Transfer	Date of Transfer

Step 1 of 28

SECTION 1: NAME & CONTACT INFORMATION

SECTION 2: MARITAL INFORMATION

Client's Former Spouse

Client's Second Former Spouse

Spouse's Former Spouse

Spouse's Second Former Spouse

SECTION 3: CHILDREN

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

SECTION 4: DISPOSITIVE PLANNING

SECTION 5: FIDUCIARIES

Executors

Executor 1

Executor 2

Executor 3

Trustees

Trustee 1

Trustee 2

Trustee 3

Trustee 4

Guardians of Minor Children

Guardian 1

Guardian 2

Agents Under Power of Attorney

Agent 1

Agent 2

Agent 3

Agents Under Health Care Power of Attorney

Agent 1

Agent 2

SECTION 6: HEALTH-RELATED PROBLEMS

SECTION 7: CAPACITY

Client

Spouse

SECTION 8: PHYSICIAN INFORMATION

Client

Spouse

SECTION 9: RESIDENCE

Owned

Rented

SECTION 11: LONG-TERM CARE (LTC)

Client

Spouse

SECTION 12: HOSPITAL

SECTION 13: INCOME

FIXED MONTHLY INCOME

Monthly Social Security Income

Monthly R.R. Retirement Income

Monthly Pension Income

Other Monthly Income

Other Monthly Income

NON-FIXED MONTHLY INCOME

Monthly Interest Income

Monthly Dividends Income

Other Non-Fixed Monthly Income

Other Non-Fixed Monthly Income

TOTALS

SECTION 14: ASSETS & RESOURCES

Personal Property

SECTION 15: EXEMPT RESOURCES

SECTION 16: PEOPLE PROVIDING ASSISTANCE

Responsible for Client

Responsible for Spouse

SECTION 17: UNAVAILABLE CHILDREN

SECTION 18: MONTHLY COST OF LIVING

Housing (Estimated Per Month)

Insurance Premiums (Per Month)

Medical Expenses (Estimated Per Month)

Basic Living Expenses (Estimated Per Month)

TOTALS

SECTION 19: HEALTH AND LONG-TERM CARE INSURANCE

SECTION 20: PLANNING AND OTHER DOCUMENTS

SECTION 21: TRANSFERS WITHIN 60 MONTHS

SECTION 22: TRANSFERS TO OR FROM TRUSTS

SECTION 23: CLIENT'S GOALS