Long-Term Care Planning Worksheet

LONG-TERM CARE PLANNING WORKSHEET

This worksheet will be a starting point for our interview, where we will discuss any additional necessary information. Please note that we charge a flat fee, transactional rate of $800.00 for long-term care planning matters, which fee includes an hour-long consultation, written explanation and recommendations, and related phone calls and emails as necessary. As such, there is a charge for the initial consultation (which fee includes the follow-up work as referenced in our engagement letter). We will send you an engagement letter before the initial consultation, which gives you the opportunity to review the terms of the engagement and agree to the same prior to the consultation. We will require that you submit the retainer for attorney fees and signed engagement letter at or before the initial consultation and prior to receiving advice from the attorney. If additional steps are necessary to achieve or maintain eligibility for government benefits other than those stated herein, such as preparation of real estate, loan, care provider, estate planning or trust documents, or an application for Medicaid benefits, additional fees will be required. A reduced rate will be applied to long-term care matters handled in conjunction with estate planning matters.

PLEASE USE SECTION VI IF ADDITIONAL SPACE IS REQUIRED.

I. PERSONAL INFORMATION

1. Applicant (Individual in need of care)Citizenship

Home Address E-mail

Telephone County

Birth Date Soc. Sec. No.

2. Spouse’s Name Citizenship

Home Address E-mail

Telephone County

Birth Date Soc. Sec. No.

3. Children's Names: (Living and Deceased—Use Additional Sheet If Necessary)

Child's Name

Address E-mail

Telephone Birth Date Is Child Disabled

Spouse’s Name

Child's Name

Address E-mail

Telephone Birth Date Is Child Disabled

Spouse’s Name

Child's Name

Address E-mail

Telephone Birth Date Is Child Disabled

Spouse’s Name

Child's Name

Address E-mail

Telephone Birth Date Is Child Disabled

Spouse’s Name

II. ASSETS

*If property is held in more than one name, state whether joint with right of survivorship or tenants in common. State also in whose names the property is held jointly if other than husband and wife. PLEASE PROVIDE COPIES OF ALL DEEDS, ACCOUNT STATEMENTS, ANNUITIES, INSURANCE POLICIES, ETC.

A.REAL ESTATE. Please list all real estate owned partially or wholly by the Applicant or the Applicant’s spouse.

Owner(s)Property AddressValue and Amount Owed

B.CASH. Please list all cash held partially or wholly by the Applicant of the Applicant’s spouse. Please include cash on hand, savings accounts, checking accounts, CDs, or Money Market Accounts.

Owner(s)Description (Bank, etc.)Account No.Value

C.SECURITIES AND BONDS. Please list all publicly traded securities (stocks) and bonds (including US Savings Bonds) held partially or wholly by the Applicant or the Applicant’s spouse.

Owner(s)Description (Company, etc.)Account No.Value

D.CLOSELY HELD BUSINESS. Please list all closely held business interests of the Applicant or the Applicant’s spouse. Please provide a copy of any Buy-Sell Agreement if applicable, and a copy of a business valuation if one is available.

Owner(s)Business NameValue

E.AUTOMOBILES. Please list all automobiles owned by the Applicant or the Applicant’s spouse.

Owner(s)Description (Type, Year, Make, Model)ValueAmt Owed

.IRAs, 401Ks and RETIREMENTS ACCOUNTS. Please list all IRAs, 401Ks, and other Retirement Accounts (including Employer Sponsored Benefit Plans) owned by the Applicant or the Applicant’s spouse. Also, please indicate if monthly payments are being made pursuant to the retirement plan or account.

Owner(s)Description (Bank, etc.)Account No.Value

F.ANNUITIES. Please list Annuities (including Employer Sponsored Benefit Plans) owned by the Applicant or the Applicant’s spouse. Also, please indicate if monthly payments are being made pursuant to the retirement plan or account.

Owner(s)Description (Bank, etc.)Account No.ValueDate of

Purchase

G.LIFE INSURANCE. Please complete the attached life insurance policy schedule attached hereto for life insurance policies owned by the Applicant or the Applicant’s spouse.

H.IRREVOCABLE FUNERAL/BURIAL CONTRACTS. Please list all pre-need, irrevocable funeral and burial contracts in the name of the Applicant, or the Applicant’s spouse.

Owner(s)Funeral HomeValue

Date Purchased: ______

Paid in Full? (If yes, list purchase price; if no, list what has been paid to date):______.

Value of any paid-in-full burial space items: ______(these should be noted on the contract).

I.ADDITIONAL PROPERTY AND ASSETS. Please list any other property or asset owned by the Applicant, or the Applicant’s spouse.

Owner(s)DescriptionValue

III. LIABILITIES

Please provide information with respect to the debts and liabilities of the Applicant and the Applicant’s spouse.

Type of DebtDebtor(s)CreditorTotal DebtPayment

Mortgage$$

Home Equity$$

Car Loan$$

Life Ins. Loan$$

Mortgage$$

Credit Card$$

Miscellaneous$$

Please provide information concerning the monthly living and housing expenses of the Applicant and the Applicant’s spouse.

ExpenseMonthly Payment

Mortgage/Rent$

Real Estate Taxes$

Property Insurance$

Condo Maintenance Fees$

Please provide information concerning the monthly medical and prescription expenses of the Applicant and the Applicant’s spouse.

ExpenseMonthly Expenses

Applicant’s Non-Reimbursed Medical Expenses$

Spouse’s Non-Reimbursed Medical Expenses$

Applicant’s Non-Reimbursed Prescription Expenses$

Spouse’s Non-Reimbursed Prescription Expenses$

Please provide information concerning the monthly medical and prescription deductibles and co-payments of the Applicant and the Applicant’s spouse. This would include any deductible or co-payment for Medicare Part B and Medicare Part D.

ExpenseDescriptionMonthly Expenses

Applicant’s Deductible/Co-Payment$

Spouse’s Deductible/Co-Payment$

Qualified Income Trust Drafting:

Who will be the Trustee of the Qualified Income Trust?______

Who will be the Alternate Trustee? ______

Is there an existing power of attorney for the Medicaid Recipient?____Yes ____No (If “Yes” submit a copy)

IV. INCOME

Please provide information concerning the GROSS monthly income (i.e. before deductions are taken for taxes, Medicare premiums, etc.) of the Applicant and the Applicant’s spouse. This includes social security, pension, IRA and 401K income as well as earned income. Note: the amount deposited in the Applicant’s account each month is not the gross amount. Please verify gross income via paystub, benefit award letter, or the like.

Income RecipientDescription/SourceMonthly Amount

Applicant$

Spouse$

V. GIFTS

Please provide a list of gifts made by the Applicant or the Applicant’s spouse within the last 5 YEARS. This would include cash gifts and transfer of real estate to others.

Date of GiftGift RecipientSource of Gift (Savings Acc’t, etc.)Amount of Gift

VI. MISCELLANEOUS

1.Please note any needed or anticipated major expenses including a new home, car or appliances; home repairs; elective medicaldental procedures:

2.Are you or your spouse veterans? If so, list the branch of service and all dates of active service, including your discharge date:

3.Are VA benefits being received?

4.Do you have long-term care insurance?

5.Is there Medigap insurance?

6.If receiving skilled nursing, is Medicare paying?

7.If yes to number 6, when does the 100 Day period expire?

8.Please provide the exact dates of admission and discharge to and from a hospital and/or nursing home; the name of each facility; the daily nursing home rate; and whether the nursing home accepts Medicaid:

9.If not yet admitted to a hospital or nursing home, please provide the date this is expected to occur:

10.Please state whether the applicant/patient was ever previously admitted to a hospital and/or a nursing home for a period of thirty consecutive days, and if so, please provide the exact dates of admission and discharge to and from a hospital and/or nursing home and the name of each facility:

11.What is the likelihood the applicant/patient will return home?

12.Is a family member living is the patient’s/applicant’s home, and if so, please provide the full name and relationship of this individual(s):

13.What are the expectations of selling the home?

14.Is there a financial power of attorney in place? If so, please provide a copy of the power(s) of attorney.

15.Does the applicant need assistance with any of the following activities of daily living? Check all that apply.

□Bathing/Showering

□Dressing

□Transferring in and out of bed/chair

□Eating

□Using toilet

□Walking

□Medication Administration

□Meal preparation

□Managing money

□Shopping for groceries or clothing

□Use of telephone

□Transportation within community

LIFE INSURANCE POLICY SCHEDULE

Please complete the following schedule for life insurance owned by the Applicant or the Applicant’s Spouse

Insurance Company______

Account Number______

Owner______

Beneficiary______

Insured______

Cash Surrender Value______

Face Value______

Death Benefit ______

Type (Term/Whole/______

Universal/Permanent/Etc.)

Insurance Company______

Account Number______

Owner______

Beneficiary______

Insured______

Cash Surrender Value______

Face Value______

Death Benefit ______

Type (Term/Whole/______

Universal/Permanent/Etc.)

Insurance Company______

Account Number______

Owner______

Beneficiary______

Insured______

Cash Surrender Value______

Face Value______

Death Benefit ______

Type (Term/Whole/______

Universal/Permanent/Etc.)

ACKNOWLEDGMENT

The undersigned states that the information provided to the Hill & Watchko, LLC in the above questionnaire is true and correct to the best of our ability and will provide any updated information obtained to Hill & Watchko, LLC prior to the submission of the Medicaid Application or the execution of any Trust document or agreement related to the Medicaid planning process.

______(Signature)

Printed Name:______

______(Signature)

Printed Name:______