CONFIDENTIAL LONG TERM CARE PLANNING QUESTIONNAIRE

The following questionnaire 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: 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.
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Name(Required)
Address(Required)
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Spouse / Partner Name
MM slash DD slash YYYY

Family Information

Please use this section to list Children, Grandchildren and other relatives you would like to include in your planning.
Relatives
Name
Relation
Date of Birth
Address
 
Please use the + button to the right to add additional beneficiaries.
Do the Individual(s) Needing Care Have Any Living Children Who Are Disabled?

Business Interests

Please provide detail regarding any business interests you hold
Are you interested in Succession Planning

Professional Advisors

Please provide contact information for attorneys, financial advisors, brokers, insurance agents, etc.
Advisor
Name
Title
Email Address
Phone Number
 
Please use the + button to the right to add additional advisors.

Health Related Information

Are there any known issues with the individual's memory or understanding
Is the individual able to sign their name?
Is the individual able to speak?
Is the individual able to recognize family members and acquaintances?
Is the individual cognizant of their property and possessions?
Is the individual able to travel outside their current place of residence?
Is either individual currently in a hospital?
Is either individual currently receiving Long Term Care?

Physician Information (Client)

Please list Physician name(s) and address(es)
Name
Phone Number
Specialty
 
Please use the + to the right to add additional physicians

Health and LTC Insurance

Please provide information regarding Medicare Parts A, B and/or D, private health or long term care insurance or Medicare supplement policy
Policy Information
Name of Insurer
Policy Number
Type of Coverage
Monthly Premium
 
Please use the + to the right to add additional policies

Assets

Please 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 Source
Amount
 
Please use the + button to the right to add additional income.
Bank Accounts
Name of Financial Institution
Account Value
Purpose of Account
 
Please use the + button to the right to add additional accounts.
Do you own or rent your current residence?
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?
Has The Child Provided Personal Care to the Parent(s) That Might Have Delayed The Need For Long Term Care For The Parent?
Please List Any Valuable Personal Property (ie: Vehicles, Jewelery, Home Furnishings, Artwork)
Please use the + button to the right to add additional personal property.
Exempt Resources
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 items
Has the individual transferred property to someone other than their spouse within the past 60 months?
If Yes, Please Complete the Following
Recipient
Amount
Date
 
Please use the + to the right to add additional recipients
Have Gift Tax Returns Been Filed On Any Gifts?
If Yes, Please Complete the Following
Name of Trust
Amount
Date
 
Please use the + to the right to add additional trusts
Has the Individual Transferred Property Into a Trust, or Directed That Property be Transferred From a Trust Within the Past 60 Months?
If Yes, Please Complete the Following
Recipient
Amount
Date
 
Please use the + to the right to add additional returns

Personal Representatives

These are people you trust to represent you and carry out your wishes, financial and otherwise.
Who Do You Trust to Make Financial Decisions?
Name
Address
 
Please use the + button to the right to add additional people.
Who Do You Trust to Make Healthcare Decisions?
Name
Address
 
Please use the + button to the right to add additional people.
Who Do You Trust to Take Care of Your Children?
Name
Address
 
Please use the + button to the right to add additional people.
Who Do You Trust to Take Care of Your Pets?
Name
Address
 
Please use the + button to the right to add additional people.

Specific Bequests

Are there any specific requests you want to discuss in your appointment (ie: charitable gifts, items or money to go to specific people?)

Thank You

Thank 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.
Please provide any relevant documents you would like to share with our attorneys.
Drop files here or
Max. file size: 20 MB.

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