CONFIDENTIAL LONG TERM CARE PLANNING QUESTIONNAIREPlease read the following instructions carefully. The questionnaire below is designed to expedite our efforts complete your long term care planning. Whether you are a new or an established client, we have found this questionnaire extremely helpful, and therefore ask you to complete it prior to your appointment. Those questions that do not apply to your family or financial situation may simply be left blank. Please feel free to attach additional pages where space is needed or to provide other information you feel is relevant. There is a space below to upload any of your documents securely. Our site uses SSL Encryption to protect your data. NOTE: DO NOT RELOAD OR REFRESH THIS PAGE AS YOU COMPLETE THE FORM, AS THAT MAY CAUSE YOUR INFORMATION TO BE DELETED. IF YOU NEED TO COME BACK TO COMPLETE THE QUESTIONNAIRE, YOU CAN HIT “SAVE AND CONTINUE” AT THE BOTTOM OF THIS PAGE. YOU WILL RECEIVE AN EMAIL WITH A LINK TO CONTINUE/COMPLETE THE QUESTIONNAIRE. Today's Date:(Required) MM slash DD slash YYYY Name(Required) First Middle Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth MM slash DD slash YYYY Phone(Required)Phone (Other)Email(Required) EmployerSpouse / Partner Name First Middle Last Date of Marriage or Domestic Partnership MM slash DD slash YYYY State of Marriage or Domestic PartnershipFamily InformationPlease use this section to list Children, Grandchildren and other relatives you would like to include in your planning.RelativesNameRelationDate of BirthAddress Add RemovePlease use the + button to the right to add additional beneficiaries. Do the Individual(s) Needing Care Have Any Living Children Who Are Disabled? Yes No If Yes, Please Provide a Brief Description of the DisabilityBusiness InterestsPlease provide detail regarding any business interests you holdName of BusinessEstimated Business ValueBusiness AddressAre you interested in Succession Planning Yes No Unsure Professional AdvisorsPlease provide contact information for attorneys, financial advisors, brokers, insurance agents, etc.AdvisorNameTitleEmail AddressPhone Number Add RemovePlease use the + button to the right to add additional advisors. Health Related InformationPlease provide information regarding any specific health related problems/concernsAre there any known issues with the individual's memory or understanding Yes, Client Yes, Spouse/Significant Other If you answered yes, please describe the nature of the problemIs the individual able to sign their name? Yes, Client No, Client Yes, Spouse/Significant Other No, Spouse/Significant Other Is the individual able to speak? Yes, Client No, Client Yes, Spouse/Significant Other No, Spouse/Significant Other Is the individual able to recognize family members and acquaintances? Yes, Client No, Client Yes, Spouse/Significant Other No, Spouse/Significant Other Is the individual cognizant of their property and possessions? Yes, Client No, Client Yes, Spouse/Significant Other No, Spouse/Significant Other Is the individual able to travel outside their current place of residence? Yes, Client No, Client Yes, Spouse/Significant Other No, Spouse/Significant Other Is either individual currently in a hospital? Yes, Client Yes, Spouse/Significant Other If yes, please provide the name and location of the hospital, as well as the date admitted and a brief description of the medical problemIs either individual currently receiving Long Term Care? Yes, Client Yes, Spouse/Significant Other Name of LTC Facility/ProviderAddress of LTC Facility/ProviderPrimary Contact and Telephone NumberPhysician Information (Client)Please list Physician name(s) and address(es)NamePhone NumberSpecialty Add RemovePlease use the + to the right to add additional physiciansHealth and LTC InsurancePlease provide information regarding Medicare Parts A, B and/or D, private health or long term care insurance or Medicare supplement policyPolicy InformationName of InsurerPolicy NumberType of CoverageMonthly Premium Add RemovePlease use the + to the right to add additional policiesAssetsPlease provide information regarding any personal assets. If you have statements, deeds, property tax bills, etc., please attach them below, or bring them to your appointment. Please List Any Monthly Family Income (ie: Wages, Social Security, Retirement, Other)Income SourceAmount Add RemovePlease use the + button to the right to add additional income. Bank AccountsName of Financial InstitutionAccount ValuePurpose of Account Add RemovePlease use the + button to the right to add additional accounts. Do you own or rent your current residence? Own Rent What is the monthly rent or mortgage?If Owned, Who Holds the Mortgage?What is the Estimated Market Value?What is the Amount MortgagedWhen Does the Mortgage Mature?Is At Least One Occupant of the Residence a Child Of the Individual Needing Long Term Care Who Has Lived in the Residence For At Least Two Years? Yes No Has The Child Provided Personal Care to the Parent(s) That Might Have Delayed The Need For Long Term Care For The Parent? Yes No If Yes, Please Describe the Nature and Duration of the Care ProvidedPlease List Any Valuable Personal Property (ie: Vehicles, Jewelery, Home Furnishings, Artwork) Add RemovePlease use the + button to the right to add additional personal property. Exempt Resources Burial Plot Irrevocable burial fund contract Under the Medicaid rules, the above items are exempt from consideration as an available asset to pay for long term care. Please indicate whether the individual needing care has the listed itemsHas the individual transferred property to someone other than their spouse within the past 60 months? Yes No If Yes, Please Complete the FollowingRecipientAmountDate Add RemovePlease use the + to the right to add additional recipientsHave Gift Tax Returns Been Filed On Any Gifts? Yes No If Yes, Please Complete the FollowingName of TrustAmountDate Add RemovePlease use the + to the right to add additional trustsHas the Individual Transferred Property Into a Trust, or Directed That Property be Transferred From a Trust Within the Past 60 Months? Yes No If Yes, Please Complete the FollowingRecipientAmountDate Add RemovePlease use the + to the right to add additional returnsPersonal RepresentativesThese are people you trust to represent you and carry out your wishes, financial and otherwise.Who Do You Trust to Make Financial Decisions?NameAddress Add RemovePlease use the + button to the right to add additional people. Who Do You Trust to Make Healthcare Decisions?NameAddress Add RemovePlease use the + button to the right to add additional people. Who Do You Trust to Take Care of Your Children?NameAddress Add RemovePlease use the + button to the right to add additional people. Who Do You Trust to Take Care of Your Pets?NameAddress Add RemovePlease use the + button to the right to add additional people. Specific BequestsAre there any specific requests you want to discuss in your appointment (ie: charitable gifts, items or money to go to specific people?)If yes, please describe them here:Please Provide Specific Funeral Instructions, If Any (ie: Cremation, Memorial Service, Services)Who would you like to handle your remains and final arrangements?AddressThank YouThank you for taking the time to complete this questionnaire; it is very helpful for your appointment. If you have any questions regarding this questionnaire or your appointment, please contact James Gonda at 518-459-2100.Upload Files Securely Here (ie: bank statements, tax documents, deeds, etc.)Please provide any relevant documents you would like to share with our attorneys. Drop files here or Select files Max. file size: 20 MB.
