Long-Term Care Planning Questionnaire

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SECTION 1: NAME & CONTACT INFORMATION

Person Completing Form

First Middle Last

Address

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

Relationship to Client

Client's Full Name

First Middle Last Suffix

Spouse's Full Name

First Middle Last Suffix

Home Address

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

Client Primary Phone

Client Secondary Phone

Spouse Primary Phone

Spouse Secondary Phone

Client Date of Birth

MM slash DD slash YYYY

Spouse Date of Birth

MM slash DD slash YYYY

Client Former/Maiden Name

Spouse Former/Maiden Name

Is client a U.S. Citizen?

Yes

Is spouse a U.S. Citizen?

Yes

Client Military Service

Spouse Military Service

Client Date of Death

MM slash DD slash YYYY

Spouse Date of Death

MM slash DD slash YYYY

SECTION 2: MARITAL INFORMATION

Date of Marriage

MM slash DD slash YYYY

Place of Marriage

City State / Province / Region Country

Does the client have a former spouse(s)?

Yes

Client's Former Spouse

Name of Former Spouse

First Middle Last Suffix

Date of Marriage

MM slash DD slash YYYY

Place of Marriage

Year terminated

Marriage was terminated due to

Death

Divorce

Is the former spouse still living?

Yes

If yes, describe relationship.

Does the client have an additional former spouse?

Yes

Client's Second Former Spouse

Name of Former Spouse

First Middle Last Suffix

Date of Marriage

MM slash DD slash YYYY

Place of Marriage

Year Terminated

Marriage was terminated due to

Death

Divorce

Is the former spouse still living?

Yes

If yes, describe relationship.

Does client's current spouse have a former spouse(s)?

Yes

Spouse's Former Spouse

Name of Former Spouse

First Middle Last Suffix

Date of Marriage

MM slash DD slash YYYY

Place of Marriage

Year Terminated

Marriage was terminated due to:

Death

Divorce

Is the former spouse still living?

Yes

If yes, describe the relationship.

Does client's current spouse have an additional former spouse?

Yes

Spouse's Second Former Spouse

Name of Former Spouse

First Middle Last Suffix

Date of Marriage

MM slash DD slash YYYY

Place of Marriage

Year Terminated

Marriage was terminated due to:

Death

Divorce

Is the former spouse still living?

Yes

If yes, describe relationship

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

MM slash DD slash YYYY

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

Child 1 Date of Adoption

MM slash DD slash YYYY

Court Granting Adoption of Child 1

Is child 1 deceased?

Yes

Child 1 Date of Death

MM slash DD slash YYYY

Does child 1 have surviving children?

Yes

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

MM slash DD slash YYYY

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

Child 2 Date of Adoption

MM slash DD slash YYYY

Court Granting Adoption of Child 2

Is child 2 deceased?

Yes

Child 2 Date of Death

MM slash DD slash YYYY

Does child 2 have surviving children?

Yes

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

MM slash DD slash YYYY

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

Child 3 Date of Adoption

MM slash DD slash YYYY

Court Granting Adoption of Child 3

Is child 3 deceased?

Yes

Child 3 Date of Death

MM slash DD slash YYYY

Does child 3 have surviving children?

Yes

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

MM slash DD slash YYYY

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

Child 4 Date of Adoption

MM slash DD slash YYYY

Court Granting Adoption of Child 4

Is child 4 deceased?

Yes

Child 4 Date of Death

MM slash DD slash YYYY

Does child 4 have surviving children?

Yes

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

MM slash DD slash YYYY

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

Child 5 Date of Adoption

MM slash DD slash YYYY

Court Granting Adoption of Child 5

Is child 5 deceased?

Yes

Child 5 Date of Death

MM slash DD slash YYYY

Does child 5 have surviving children?

Yes

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

MM slash DD slash YYYY

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

Child 6 Date of Adoption

MM slash DD slash YYYY

Court Granting Adoption of Child 6

Is child 6 deceased?

Yes

Child 6 Date of Death

MM slash DD slash YYYY

Does child 6 have surviving children?

Yes

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

SECTION 4: DISPOSITIVE PLANNING

In general, to whom and how do you want your property distributed upon your death? Think about your family members, friends, former benefactors, and charities, such as nonprofit organizations, educational, or religious organizations. Consider to whom (charities, other siblings, spouse of child, etc.) your property should go if your first-choice beneficiaries do not survive you, or if those beneficiaries do not survive until complete distribution is made should the property be left in a trust.

First Choice Beneficiaries

Spouse

Children

Spouse & Children

Other

First Choice Beneficiaries Names

Second Choice Beneficiaries

Spouse

Children

Spouse & Children

Other

Second Choice Beneficiaries Names

Third Choice Beneficiaries

Spouse

Children

Spouse & Children

Other

Third Choice Beneficiaries Names

Any specific disposition of your residence?

Any specific gifts of special articles, such as art or jewelry?

Any specific disposition of household and personal effects or other information you think is important to your estate planning?

SECTION 5: FIDUCIARIES

Please consider who you want to handle your affairs when you cannot. We will discuss this section at our conference and may assist you with completion.

Executors

Co-Executors Act:

Separately

Jointly

Executor 1

Executor 1 Name

First Middle Last

Executor 1 Relationship

Executor 1 Address

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

Executor 1 Phone Number

Executor 2

Executor 2 Name

First Middle Last

Executor 2 Relationship

Executor 2 is a:

Co-Executor

Successor Executor

May surviving Co-Executor act alone?

Yes

Executor 2 Address

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

Executor 2 Phone Number

Executor 3

Executor 3 Name

First Middle Last

Executor 3 Relationship

Executor 3 is a:

Co-Executor

Successor Executor

May surviving Co-Executor act alone?

Yes

Executor 3 Address

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

Executor 3 Phone Number

Trustees

Co-Trustees Act:

Separately

Jointly

Trustee 1

Trustee 1 Name

First Middle Last

Trustee 1 Relationship

Trustee 1 Address

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

Trustee 1 Phone Number

Trustee 2

Trustee 2 Name

First Middle Last

Trustee 2 Relationship

Trustee 2 is a:

Co-Trustee

Successor Trustee

May surviving Trustee Act Alone?

Yes

Trustee 2 Address

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

Trustee 2 Phone Number

Trustee 3

Trustee 3 Name

First Middle Last

Trustee 3 Relationship

Trustee 3 is a:

Co-Trustee

Successor Trustee

May surviving Trustee act alone?

Yes

Trustee 3 Address

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

Trustee 3 Phone Number

Trustee 4

Trustee 4 Name

First Middle Last

Trustee 4 Relationship

Trustee 4 is a:

Co-Trustee

Successor Trustee

May surviving Trustee act alone?

Co-Trustee

Successor Trustee

Trustee 4 Address

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

Trustee 4 Phone Number

Guardians of Minor Children

Co-Guardians Act:

Separately

Jointly

Guardian 1

Guardian 1 Name

First Middle Last

Guardian 1 Relationship

Guardian 1 Address

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

Guardian 1 Phone Number

Guardian 2

Guardian 2 Name

First Middle Last

Guardian 2 Relationship

Guardian 2 is:

Co-Guardian

Successor Guardian

May surviving Co-Guardian act alone?

Yes

Guardian 2 Address

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

Guardian 2 Phone Number

Agents Under Power of Attorney

Co-Agents Act:

Separately

Jointly

Agent 1

Agent 1 Name

First Middle Last

Agent 1 Relationship

Agent 1 Address

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

Agent 1 Phone Number

Agent 2

Agent 2 Name

First Middle Last

Agent 2 Relationship

Agent 2 is:

Co-Agent

Successor Agent

May surviving Co-Agent Act Alone?

Yes

Agent 2 Address

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

Agent 2 Phone Number

Agent 3

Agent 3 Name

First Middle Last

Agent 3 Relationship

Agent 3 is:

Co-Agent

Successor Agent

May surviving Co-Agent Act Alone?

Yes

Agent 3 Address

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

Agent 3 Phone Number

Agents Under Health Care Power of Attorney

Agent 1

Agent 1 Name

First Middle Last

Agent 1 Relationship

Agent 1 Address

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

Agent 1 Phone Number

Agent 2

Agent 2 Name

First Middle Last

Agent 2 Relationship

Agent 2 Address

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

Agent 2 Phone Number

SECTION 6: HEALTH-RELATED PROBLEMS

Please describe any health-related problems:

Client

Spouse

SECTION 7: CAPACITY

Client

Does the client have any problems with memory or understanding?

Yes

Please explain.

Is the client able to sign name?

Yes

Is the client able to speak?

Yes

Is the client able to recognize friends & family?

Yes

Is the client cognizant of property and posessions?

Yes

Is the client able to leave current residence?

Yes

Spouse

Does the spouse have any problems with memory or understanding?

Yes

Please explain.

Is the spouse able to sign name?

Yes

Is the spouse able to speak?

Yes

Is the spouse able to recognize friends & family?

Yes

Is the spouse cognizant of property and posessions?

Yes

Is the spouse able to leave current residence?

Yes

SECTION 8: PHYSICIAN INFORMATION

Client

Client's Physician's Name

First Middle Last Suffix

Client's Physician's Specialty

Client's Physician's Address

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

Client's Physician's Phone Number

Spouse

Spouse's Physician's Name

First Middle Last Suffix

Spouse's Physician's Specialty

Spouse's Physician's Address

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

Spouse's Physician's Phone Number

SECTION 9: RESIDENCE

Does client own or rent current residence?

Own

Rent

Owned

PLEASE PROVIDE A COPY OF THE DEED AND MOST RECENT TAX BILL

Owners:

How is title held?

Fair Market Value ($)

Mortgage Value ($)

Is it a Reverse Annuity Mortgage (RAM)?

Yes

Basic Mortgage Terms:

Single Family Residence?

Yes

Is the property a rental property?

Yes

Number of Units

Currently being rented?

Yes

Are tentants under lease?

Yes

Was property purchased or inherited?

Purchased

Inherited

Date of Purchase:

MM slash DD slash YYYY

Purchase Price:

Month & Year Inherited

Value when inherited:

Have improvements been made to the property?

Yes

Please detail the value and nature of the improvements:

Have the owners used the capital gains tax exclusion?

Yes

If at least one occupant of the residence is a child of the individual in need of long-term care, has that child lived in the residence for at least 2 years?

Yes

Has the child provided personal care to the parent that might have delayed the need for long-term care for the parent?

Yes

Please describe the nature and duration of the care provided:

Does the person needing care have any living children who are disabled?

Yes

Please describe the nature of the disability.

Does the owner have a sibling who has lived in the house for at least 1 year?

Yes

Does the sibling still reside in the home?

Yes

Rented

Monthly Rent

Type of Rental

Single Family

Apartment

Residential Care

Life Care

Senior Housing

Rental/Lease Agreement?

Yes

Is rent subsidized?

Yes

Subsidized by whom?

Subsidized amount:

SECTION 11: LONG-TERM CARE (LTC)

Is client currently receiving LTC?

Yes

Is spouse currently receiving LTC?

Yes

Client

Date Client LTC Started

MM slash DD slash YYYY

Name of Client's Facility/Provider

Client LTC Address

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

Client's LTC Phone Number

Administrator or Contact:

Spouse

Date Spouse LTC Started

MM slash DD slash YYYY

Name of Spouse's Facility/Provider

Spouse LTC Address

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

Spouse's LTC Phone Number

Administrator or Contact:

SECTION 12: HOSPITAL

Is client currently in the hospital?

Yes

Is spouse currently in the hospital?

Yes

Date Client Admitted to the Hospital:

MM slash DD slash YYYY

Name/Location of Hospital Client is In:

Description of Client's Medical Issue:

Is Long Term Care for client expected?

Yes

Is client expected to return home?

Yes

Date Spouse Admitted to the Hospital:

MM slash DD slash YYYY

Name/Location of Hospital Spouse is In:

Description of Spouse's Medical Issue:

Is Long Term Care for spouse expected?

Yes

Is client expected to return home?

Yes

SECTION 13: INCOME

In completing the following section, use the “name on the check” rule; that is, the person whose name appears on the payment vehicle is the “owner” of the income.

FIXED MONTHLY INCOME

Monthly Social Security Income

Client

Spouse

Both

Monthly R.R. Retirement Income

Client

Spouse

Both

Monthly Pension Income

Client

Spouse

Both

Other Monthly Income

Source of Other Monthly Income

Client

Spouse

Both

Other Monthly Income

Source of Other Monthly Income

Client

Spouse

Both

NON-FIXED MONTHLY INCOME

Monthly Interest Income

Client

Spouse

Both

Monthly Dividends Income

Client

Spouse

Both

Other Non-Fixed Monthly Income

Source of Other Non-Fixed Monthly Income

Client

Spouse

Both

Other Non-Fixed Monthly Income

Source of Other Non-Fixed Monthly Income

Client

Spouse

Both

TOTALS

Total Client Fixed & Non-Fixed Monthly Income:

(calculates automatically)

Total Spouse Fixed & Non-Fixed Monthly Income:

(calculates automatically)

Total Both Fixed & Non-Fixed Monthly Income:

(calculates automatically)

SECTION 14: ASSETS & RESOURCES

Cash & Bank Accounts (CDs, Checking, Savings, etc.)

Please provide copies of statements. Add as many rows as needed.

Name of Bank/Branch

Account No.

Type of Account

Balance/Value

How Title Held

Securities (Bonds, Marketable Securities, etc.)

Please provide copies of statements. Add as many rows as needed.

Name of Company

Type of Sec.

# Shares/Face Val.

Cost

Current Val.

How Title Held

Retirement Accounts (IRAs, Keoghs, etc.)

Please provide copies of statements & beneficiary designation. Add as many rows as needed.

Name of Institution

Account No.

Owner

Beneficiary

Date Established

Current Value

Real Estate

Please provide copies of deeds & most recent tax bills. Add as many rows as needed.

Description (Location)

Cost (Basis)

Market Value

Mortgage Balance

How Title Held

Personal Property

Home Furnishings

Add as many rows as needed.

Item

Market Value

How Title Held

Cars, RVs, Boats, etc.

Add as many rows as needed.

Item

Market Value

How Title Held

Jewels, Furs, etc.

Add as many rows as needed.

Item

Market Value

How Title Held

Other Personal Property

Add as many rows as needed.

Item

Market Value

How Title Held

Business Interests

If the person needing long-term care has any business interests, please provide a short description giving the name, location, percentage owned, names, relationship of co-owners, and the form of ownership (i.e., sole proprietorship, closely held corporation, partnership, etc.).

RIGHTS OR INTERESTS IN TRUSTS, ESTATES, OR PROSPECTIVE INHERITANCES

Briefly describe or give the name of the Trust in which the person needing long-term care has an interest, or the person who is the source of the inheritance. Please provide a copy of the instrument which creates the interest, if available. If not, please advise how we may obtain a copy.

MISCELLANEOUS

If the person needing long-term care has any property interests not described above, please explain the nature of the interests and the estimated value of each.

SECTION 15: EXEMPT RESOURCES

Under the Medicaid rules, certain items are “exempt” from consideration as an available asset to pay for long-term care. Some of those items are listed below. Please indicate whether the person needing care has the listed items.

Does client have a burial plot?

Yes

Does spouse have a burial plot?

Yes

Does client have an irrevocable burial fund contract?

Yes

Does spouse have an irrevocable burial fund contract?

Yes

SECTION 16: PEOPLE PROVIDING ASSISTANCE

Who now has “assistance” responsibilities? That is, are any family members or other people providing custodial or other types of care to the person needing assistance?

Responsible for Client

Name of Person 1 Responsible for Client

First Last

Phone Number for Person 1 Responsible for Client

Relationship of Person 1 Responsible for Client

Name of Person 2 Responsible for Client

First Last

Phone Number for Person 2 Responsible for Client

Relationship of Person 2 Responsible for Client

Responsible for Spouse

Name of Person 1 Responsible for Spouse

First Last

Phone Number for Person 1 Responsible for Spouse

Relationship of Person 1 Responsible for Spouse

Name of Person 2 Responsible for Spouse

First Last

Phone Number for Person 2 Responsible for Spouse

Relationship of Person 2 Responsible for Spouse

SECTION 17: UNAVAILABLE CHILDREN

If the person needing care has any children who are not to be relied upon to help with management or other needs of the parent, please list those children here and briefly explain why you believe they should not be relied upon.

SECTION 18: MONTHLY COST OF LIVING

Housing (Estimated Per Month)

If home is owned, include total cost of mortgage, taxes, utilities, and phone, etc. for:

If home is OWNED, include total cost of mortgage, taxes, utilities & phone, etc. for CLIENT:

If home is OWNED, include total cost of mortgage, taxes, utilities & phone, etc. for SPOUSE:

If home is OWNED, include total cost of mortgage, taxes, utilities & phone, etc. for JOINT:

If home is RENTED, include total rent, including maintenance fees, if any, for CLIENT:

If home is RENTED, include total rent, including maintenance fees, if any, for SPOUSE:

If home is RENTED, include total rent, including maintenance fees, if any, for JOINT:

Is the senior citizen real property tax exemption being used?

Yes

Is the veterans’ real property tax exemption being used?

Yes

Insurance Premiums (Per Month)

Monthly HEALTH insurance premium for CLIENT:

Monthly HEALTH insurance premium for SPOUSE:

Monthly HEALTH insurance premium for JOINT:

Monthly LONG-TERM CARE insurance premium for CLIENT:

Monthly LONG-TERM CARE insurance premium for SPOUSE:

Monthly LONG-TERM CARE insurance premium for JOINT:

Is there an additional monthly insurance premium to report?

Yes

Type of Insurance

ADDITIONAL monthly insurance premium for CLIENT:

ADDITIONAL monthly insurance premium for SPOUSE:

ADDITIONAL monthly insurance premium for JOINT:

Medical Expenses (Estimated Per Month)

Monthly Non-covered medication expenses for CLIENT:

Monthly Non-covered medication expenses for SPOUSE:

Monthly Non-covered medication expenses for JOINT:

Is there an additional monthly medical expense to report?

Yes

Type of Monthly Medical Expense

Additional Non-covered medication expenses for CLIENT:

Additional Non-covered medication expenses for SPOUSE:

Additional Non-covered medication expenses for JOINT:

Is there another additional monthly medical expense to report?

Yes

Type of Monthly Medical Expense

Additional Non-covered medication expenses for CLIENT:

Additional Non-covered medication expenses for SPOUSE:

Additional Non-covered medication expenses for JOINT:

Basic Living Expenses (Estimated Per Month)

Estimated Monthly FOOD Expense for CLIENT

Estimated Monthly FOOD Expense for SPOUSE

Estimated Monthly FOOD Expense for JOINT

Estimated Monthly ENTERTAINMENT & TRAVEL Expense for CLIENT

Estimated Monthly ENTERTAINMENT & TRAVEL Expense for SPOUSE

Estimated Monthly ENTERTAINMENT & TRAVEL Expense for JOINT

Estimated Monthly SUPPORT FOR CHILDREN Expense for CLIENT

Estimated Monthly SUPPORT FOR CHILDREN Expense for SPOUSE

Estimated Monthly SUPPORT FOR CHILDREN Expense for JOINT

Do you have an additional basic living expense to report?

Yes

Estimated Monthly ADDITIONAL BASIC LIVING Expense for CLIENT

Estimated Monthly ADDITIONAL BASIC LIVING Expense for SPOUSE

Estimated Monthly ADDITIONAL BASIC LIVING Expense for JOINT

Do you have another additional basic living expense to report?

Yes

Estimated Monthly ADDITIONAL BASIC LIVING Expense for CLIENT

Estimated Monthly ADDITIONAL BASIC LIVING Expense for SPOUSE

Estimated Monthly ADDITIONAL BASIC LIVING Expense for JOINT

TOTALS

Total Client Monthly Cost of Living

(Calculates automatically)

Total Spouse Monthly Cost of Living

(Calculates automatically)

Total Joint Monthly Cost of Living

(Calculates automatically)

SECTION 19: HEALTH AND LONG-TERM CARE INSURANCE

If the person needing care has Medicare Parts A, B, or D, private health or long-term care insurance, or is paying for a Medicare supplement policy, please provide the following information:

Add as many rows as needed.

Name of Insurer

Policy No.

Type of Policy

Monthly Premium ($)

If LTC, Daily Benefit ($)

SECTION 20: PLANNING AND OTHER DOCUMENTS

Please provide a copy of each document.

Does Client have a will?

Yes

Does Client have a Revocable Living Trust?

Yes

Does Client have a General Durable Power of Attorney?

Yes

Does Client have a Healthcare Power of Attorney (or Proxy)?

Yes

Does Spouse have a will?

Yes

Does Spouse have a Revocable Living Trust?

Yes

Does Spouse have a General Durable Power of Attorney?

Yes

Does Spouse have a Healthcare Power of Attorney (or Proxy)?

Yes

List any additional documents/planning documents that Client or Spouse has here. Please provide a copy of each.

Add as many rows as needed.

Additional Client Document

Additional Spouse Document

SECTION 21: TRANSFERS WITHIN 60 MONTHS

Has the CLIENT transferred property to someone other than his or her spouse in the past 60 months? If so list below.

Please provide copies of gift tax returns if available. Add as many rows as needed.

Recipient

Amount/Value of Gift

Date of Gift

Has the SPOUSE transferred property to someone other than his or her spouse in the past 60 months? If so list below.

Please provide copies of gift tax returns if available. Add as many rows as needed.

Recipient

Amount/Value of Gift

Date of Gift

SECTION 22: TRANSFERS TO OR FROM TRUSTS

Has the CLIENT transferred property into a Trust, or directed that property be transferred from a Trust (usually a Revocable Trust) within the past 60 months? If so list below.

Add as many rows as needed.

Name of Trust

Amount/Value of Transfer

Date of Transfer

Has the SPOUSE transferred property into a Trust, or directed that property be transferred from a Trust (usually a Revocable Trust) within the past 60 months? If so list below.

Add as many rows as needed.

Name of Trust

Amount/Value of Transfer

Date of Transfer

SECTION 23: CLIENT'S GOALS

What are your estate and long-term care planning goals?

SECTION 24: CERTIFICATION

To what email should a copy of this completed form be sent?*

Agreeance

I, the undersigned, represent to J. L. Williamson Law Group, LLC, and each of its attorneys and paralegals, that the information contained in this Long-Term Care Planning Questionnaire is accurate and complete, and that I understand that the law firm and its individual lawyers will rely on this information. I further understand that if the information contained herein is inaccurate or incomplete, the recommendations made by J. L. Williamson Law Group, LLC, may not be appropriate.

I agree.

Signature of Client or Client Representative

Date

MM slash DD slash YYYY

Signature of Spouse or Spouse Representative

Date

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.