Long-Term Care Planning Questionnaire

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Step 1 of 28

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
- No
Is spouse a U.S. Citizen?
- Yes
- No
Client Military Service
Spouse Military Service
Client Date of Death
MM slash DD slash YYYY
Spouse Date of Death
MM slash DD slash YYYY

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
- No
Guardian 2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Guardian 2 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 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 11: LONG-TERM CARE (LTC)
Is client currently receiving LTC?
- Yes
- No
Is spouse currently receiving LTC?
- Yes
- No
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 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
- No
Does spouse have a burial plot?
- Yes
- No
Does client have an irrevocable burial fund contract?
- Yes
- No
Does spouse have an irrevocable burial fund contract?
- Yes
- No

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 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 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

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

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