Cipparone & Zaccaro, PC

Client Information Form

PERSONAL DATADate: ______

Your Name:______Citizenship:______

Other names, including birth name, if applicable: ______

DOB: ______SSN: ______Place of Birth (City & State): ______

Address:______Day Phone: ______

______Evening Phone:______

E-mail Address: ______

Previous Address if lived at address for less than 36 months
______

Address:Nursing Home/Assisted Living/Rehab

______

Mailing Address: ______

Retirement Date: ______Employer: ______

Veteran: Yes ___ No ____Active Duty: Yes ____ No _____

Honorable Discharge: Yes _____ No _____Branch of Service:______

Military Service No.______Claim No. ______

During Wartime? Yes ___ No ____ Dates of Service: ______

Do you receive any Veterans Benefits? Yes ____ No ____

If so, what kind, how much and for how long: ______

Your Spouse’sName ______Citizenship: ______

Other names, including birth name, if applicable: ______

DOB: ______SSN: ______DOD if deceased: ______

Place of Birth (City & State): ______

Address if not the same as yours:______

E-mail Address: ______Day Phone: ______Evening Phone:______

Mailing Address if not the same as yours: ______

Retirement Date: ______Employer: ______

Veteran: Yes ___ No ____Active Duty: Yes ____ No _____

Honorable Discharge: Yes _____ No _____Branch of Service:______

Military Service No.______Claim No. ______

During Wartime? Yes ___ No ____ Dates of Service: ______

Do you receive any Veterans Benefits? Yes ____ No ____

If so, what kind, how much and for how long: ______

Date of Marriage: ______Date of Divorce: ______

YOUR FAMILY

Children (Name, Address, Phone, E-mail)

______
______
______
______
______
______

Do you or your spouse have children from a previous marriage? If so, which children listed above are yours and which are your spouse’s children:

______

Have any of your children died leaving children? Yes ___ No ____ If so, who are their children? (Name, Address, Phone, E-mail)

______
______
______

Are any of your children disabled? Yes ___ No _____ If yes, please explain:

______

What kind of proof of disability do you have? Doctor’s letter ___ SSI letter ___ SSDI ____

What is the child’s SSI or SSDI Number? ______

MEDICAL CONDITION

Are you or your spouse currently ill or disabled or at risk for becoming seriously ill or disabled?

Yes ___ No ____ If yes, please explain: ______

______

Your Doctor:______Phone: ______

Address: ______Fax: ______

Your Spouse’s Doctor ______Phone: ______

Address: ______Fax: ______

Have you or spouse recently entered a hospital or nursing home? Yes ____ No ______

You _____ Spouse______

Facility Name: ______Phone: ______

Date of Admission ______Fax: ______

Address: ______

Date of Discharge: ______Diagnosis: ______

If still in facility, cost of care per day:______

Facility Name: ______Phone: ______

Date of Admission ______Fax: ______

Address: ______

Date of Discharge: ______Diagnosis: ______

If still in facility, cost of care per day:______

MEDICAL INSURANCE

Medicare Nos.: ______

YoursYour Spouse’s

Health Insurance

Employer: ______

YoursYour Spouse’s

Policy No.: ______

YoursYour Spouse’s

Group No.: ______

YoursYour Spouse’s

Effective Date: ______

YoursYour Spouse’s

Medicare Supplement

Employer: ______

YoursYour Spouse’s

Policy No.: ______

YoursYour Spouse’s

Group No.: ______

YoursYour Spouse’s

Effective Date: ______

YoursYour Spouse’s

Long-Term Care Insurance

Employer: ______

YoursYour Spouse’s

Policy No.: ______

YoursYour Spouse’s

Group No.: ______

YoursYour Spouse’s

Effective Date: ______

YoursYour Spouse’s

Lifetime Cap: ______

YoursYour Spouse’s

Daily Rate: ______

YoursYour Spouse’s

Medicaid

Title 19 No.: ______

YoursYour Spouse’s

Effective Date: ______

YoursYour Spouse’s

Have you or your spouse made any gifts of $1,000 or more during the past 5 years?

Date of Gift ______Amount ______To Whom ______
Date of Gift ______Amount ______To Whom ______
Date of Gift ______Amount ______To Whom ______

If the gift was real property, please submit a market analysis of the property on the approximate date of this transfer.

ASSETS

Open Accounts(Bank accounts, CDs, Brokerage Accounts, IRAs, Annuities, etc.)

Type of Account* / Name(s) on Account / Financial Institution / Account Number / Current
Value / Beneficiary
Type of Account* / Name(s) on Account / Financial Institution / Account Number / Current
Value / Beneficiary

*Retirement, checking, savings, CD, annuity, etc.

Closed Accounts(past 3 years)

Type of Account / Name(s) on Account / Financial Institution / Account Number / Current
Value / Beneficiary

Real Estate

Address / Name(s) on Title / Purchase Date / Purchase Price / Current
Value / Mortgage (Bank, balance due)

Personal Property (Cars, RVs, Boats, Antiques, Jewelry, Collectibles, etc.)

Description of Asset / Owner(s) / Purchase Price / Current
Value / Location

Life Insurance (Group, Term & Whole Life)

Owner: ______Insured ______

Beneficiary______

Company ______Policy No. ______

Cash Value ______Face Value ______

Owner: ______Insured ______

Beneficiary______

Company ______Policy No. ______

Cash Value ______Face Value ______

Miscellaneous Assets (Nursing Home Patient Account, Business, HSA Account, etc.)

Description of Asset / Owner(s) / Purchase Price / Current Value / Location

Trusts & Inheritances

Are you or your spouse the beneficiary of any trust? Yes ______No ______

If Yes, name & address of the Trustee ______

What percentage is your share of the trust? ______How much do you receive in distributions? ______How often does the Trustee make the distribution? ______

Do you or your spouse expect an inheritance? Yes _____No ______

If yes, how much: ______When? ______

LIABILITIES

Description / Balance Due / Monthly Payment / Maturity Date

MONTHLY INCOME

Source / You / Joint / Spouse
Social Security Retirement
Social Security Disability Income (SSDI)
Supplemental Social Security Income (SSI)
Pension(s) from Work
VA Benefits/Pension
IRAs
Annuities
Interest Income (Banks)
Dividends
Business Income
Employment
Rental Income
Other Income
TOTALS

LEGAL

Location of important papers:______

Document / Agent Contact Info / Date Made
Last Will & Testament / Executor:
Durable Power of Attorney / Agent:
Appointment of Health Care Representative / Representative:
Revocable Trust / Trustee:
Special Needs Trust / Trustee:
Designation of Conservator / Conservator:

Do you have a conservator of your estate? Yes ____ No _____ If yes, is it a voluntary conservatorship or an involuntary conservatorship? ______

Probate Court: ______Date Appointed: ______

Contact Info for conservator: ______

Do you serve as conservator, power of attorney, executor for anyone?

Title of Position: ______
Name of the person: ______
Address: ______
Phone: ______Date service started: ______
Probate Court that appointed you: ______

Are you involved in any lawsuits? ______Date lawsuit started ______

Your attorney contact info ______

Anticipated settlement amount: ______

Have you ever lived in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA, WI) while married? If so, list state(s)______

PREPARATION FOR INITIAL MEETING

Please bring copies of the following documents with you to your initial meeting with the attorney:

Will, Codicil, Trust Agreements
Durable Power of Attorney, Appointment of Health Care Representative, Designation of Conservator, Disposition of Remains, Living Will
Real estate deeds, appraisals
Conservatorship documents
Caregiver Agreements
Divorce decrees, premarital agreements, adoption papers
Admission agreements to hospitals or nursing homes
Military Discharge papers
Brokerage account statements
Proof of disability, if indicated.

Contact Information of all Caregivers (other than children):

NAME / ADDRESS / E-MAIL / PHONE

Comments or other legal concerns:

______