Medicaid Crisis Questionnaire - J. L. Williamson Law Group

SECTION 9.1: CHILDREN

First Child

Name

First Middle Last

Gender

Male
Female

Date of Birth

Child is the child of

Both
Client Only
Spouse Only

Is Child a minor?

Yes
No

Do you know where the child lives?

Yes
No

If yes...

Use Client's Address
Use Spouse's Address (if different than client's)
Other Address/Lives Separately

If Other Address/Lives Separately, Enter Address Below

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

Elder Law Specific Details

Relation to Spouse

Natural Child
Adopted
Stepchild
Child born out of wedlock

Relation to Client

Natural Child
Adopted
Stepchild
Child born out of wedlock

Work Telephone

Home Telephone

Cell

Fax

Email

Special Details about Child

Disinherit child and exclude from plan
Child is an Affiant
Child will be a caregiver

Child is (check all that apply)

Stepchild
Disabled
Minor
Blind

Child's problems (check all that apply)

Poor Health
AIDS
Drug Addiction
Alcoholism
Spendthrift

Government Entitlements

Is child receiving SSI or another form of government entitlement

Yes
No

If yes, entitlement form

If yes, specify monthly payment

Do you have a second child?

Yes
No

Second Child

Name of child

First Middle Last

Gender

Male
Female

Date of Birth

Child is the child of

Both
Client Only
Spouse Only

Is child a minor?

Yes
No

Do you know where the child lives?

Yes
No

If you know where the child lives,

Use Client's Address
Use Spouse's Address (if different than client's)
Other Address/Lives Separately

If Other Address/Lives Separately, enter address below.

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

Elder Law Specific Details

Relation to Spouse

Natural Child
Adopted
Stepchild
Child born out of wedlock

Relation to Client

Natural Child
Adopted
Stepchild
Child born out of wedlock

Work Telephone

Home Telephone

Cell

Fax

Email

Special Details about child

Disinherit child and exclude from the plan
Child is an Affiant
Child will be a caregiver

Child is (check all that apply)

Stepchild
Disabled
Minor
Blind

Child's problems (check all that apply)

Poor Health
AIDS
Drug Addiction
Alcoholism
Spendthrift

Government Entitlements

Is child receiving SSI or another form of government entitlement

Yes
No

If yes, entitlement from:

Number

Do you have a third child?

Yes
No

Third Child

Child's Name

First Middle Last

Gender

Male
Female

Date of Birth

Child is the child of:

Both
Client Only
Spouse Only

Is child a minor?

Yes
No

Do you know where the child lives?

Yes
No

If you know where the child lives:

Use Client's Address
Use Spouse's Address (if different than client's)
Other Address/Lives Separately

If Other Address/Lives Separately, enter address below.

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

Elder Law Specific Details

Relation to Spouse

Natural Child
Adopted
Stepchild
Child born out of wedlock

Relation to Client

Natural Child
Adopted
Stepchild
Child born out of wedlock

Work Telephone

Home Telephone

Cell

Fax

Email

Special Details about child:

Disinherit child and exclude from the plan
Child is an Affiant
Child will be a caregiver

Child is (check all that apply):

Stepchild
Disabled
Minor
Blind

Child's problems (check all that apply):

Poor Health
AIDS
Drug Addiction
Alcoholism
Spendthrift

Government Entitlements

Is child receiving SSI or another form of government entitlement

Yes
No

If yes, entitlement from:

If yes, specify monthly payment:

Do you have a fourth child?

Yes
No

Fourth Child

Name

First Middle Last

Gender

Male
Female

Date of Birth

Child is the child of

Both
Client Only
Spouse Only

Is child a minor?

Yes
No

Do you know where the child lives?

Yes
No

If you know where the child lives...

Use Client's Address
Use Spouse's Address (if different than client's)
Other Address/Lives Separately

If Other Address/Lives Separately, enter address below.

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

Elder Law Specific Details

Relation to Spouse

Natural Child
Adopted
Stepchild
Child born out of wedlock

Relation to Client

Natural Child
Adopted
Stepchild
Child born out of wedlock

Work Telephone

Home Telephone

Cell

Fax

Email

Special Details about child

Disinherit child and exclude from the plan
Child is an Affiant
Child will be a caregiver

Child is (check all that apply)

Stepchild
Disabled
Minor
Blind

Child's problems (check all that apply)

Poor Health
AIDS
Drug Addiction
Alcoholism
Spendthrift

Government Entitlements

Is child receiving SSI or another form of government entitlement

Yes
No

If yes, entitlement from:

Specify monthly payment:

Do you have a fifth child?

Yes
No

Fifth Child

Name of Child

First Middle Last

Gender

Male
Female

Date of Birth

Child is the child of

Both
Client Only
Spouse Only

Is child a minor?

Yes
No

Do you know where the child lives?

Yes
No

If you know where the child lives:

Use Client's Address
Use Spouse's Address (if different than client's)
Other Address/Lives Separately

If Other Address/Lives Separately, enter address below.

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

Elder Law Specific Details

Relation to Spouse

Natural Child
Adopted
Stepchild
Child born out of wedlock

Relation to Client

Natural Child
Adopted
Stepchild
Child born out of wedlock

Work Telephone

Home Telephone

Cell

Fax

Email

Special Details about child

Disinherit child and exclude from the plan
Child is an Affiant
Child will be a caregiver

Child is (check all that apply)

Stepchild
Disabled
Minor
Blind

Child's problems (check all that apply)

Poor Health
AIDS
Drug Addiction
Alcoholism
Spendthrift

Government Entitlements

Is child receiving SSI or another form of government entitlement

Yes
No

If yes, entitlement from:

Specify monthly payment:

Husband	Wife	Joint	Liability

Husband	Wife	Joint	Liability

Husband	Wife	Joint	Liability

Husband	Wife	Joint	Liability

Item	Husband ($)	Wife ($)	Joint ($)	Liability ($)

Source	Amount ($)

Source	Amount ($)

Shelter Expense Name	Amount ($)

Other non-shelter expense name	Amount ($)

Step 1 of 25

SECTION 1: CONTACT PERSON

SECTION 2: CLIENT DETAILS

Family Details

Other Client Details

Domicile Details

Client Data

SECTION 3: SPOUSE DETAILS

Domicile Details

Spouse/Partner Data

SECTION 4: CLIENT MEDICAL DATA

SECTION 5: SPOUSE/PARTNER MEDICAL DATA

SECTION 6: CLIENT'S MONTHLY INCOME

SECTION 6.1: MONTHLY INCOME FOR SPOUSE/PARTNER

SECTION 6.2: MONTHLY SHELTER EXPENSES FOR SPOUSE

SECTION 6.3: MONTHLY NON-SHELTER EXPENSES FOR SPOUSE/PARTNER

SECTION 6.4: NURSING HOME COST FOR CLIENT

SECTION 7.1: NON-COUNTABLE ASSETS

SECTION 7.2: COUNTABLE ASSETS

SECTION 7.3: RESIDENCE INFORMATION

SECTION 7.4: LIFE INSURANCE

First Policy

Second Policy

SECTION 8: PRIOR TRANSACTIONS

First Gift

Second Gift

Third Gift

Fourth Gift

Fifth Gift

SECTION 8.2: Federal Gift Tax Returns

SECTION 8.3: Real Estate Transfers

First Transfer

Second Transfer

Third Transfer

Fourth Transfer

Fifth Transfer

SECTION 9.1: CHILDREN

First Child

Elder Law Specific Details

Government Entitlements

Second Child

Elder Law Specific Details

Government Entitlements

Third Child

Elder Law Specific Details

Government Entitlements

Fourth Child

Elder Law Specific Details

Government Entitlements

Fifth Child

Elder Law Specific Details

Government Entitlements

SECTION 9.2: RELATIONS & OTHER PARTIES

First Party

Second Party

Third Party

Fourth Party

Fifth Party

SECTION 10: OTHER ISSUES

SECTION 11: CERTIFICATION