KATTEN & BENSON
Attorneys at Law
4763 Barwick Drive, Suite 100
Fort Worth, Texas 76132-1531
TELEPHONE (817) 263-5190
FACSIMILE (817) 263-5197
STEVEN E. KATTEN, Attorney* KIM OLMEDO, LCSW, CCM, Elder Care Coordinator
MONICA A. BENSON, Attorney BRENDA S. EVANS, Office Manager / Paralegal
*Board Certified Estate Planning and Probate CORDY G. DAVILA, Legal Assistant
Texas Board of Legal Specialization
Certified Elder Law Attorney
Planning for care is complicated, and this questionnaire is designed to help you gather and organize as much information as possible before you meet with us. This will in turn help us make the consultation time as productive as possible.
Please take a few moments to look over and complete this questionnaire as much as possible. Don’t worry if you aren’t able to provide all the information at the consultation, but do be aware that if you engage us to do Medicaid planning, we will eventually need all requested information in order to complete the application.
If you have questions about this form, please feel free to call our office and ask for assistance.
I. Personal Information
Husband: / Wife:Address: / Date of birth:
Place of birth:
Phone: / Phone:
Email: / Email
County: / County:
Date of birth: / Date of birth:
Place of birth: / Place of birth:
SSN: / SSN:
U. S. citizen?: / Yes No / U.S. citizen?: / Yes No
Veteran?: / Yes No / Veteran?: / Yes No
Children (names, addresses):
1.2.
3.
4.
If either of youis not living at home:
Name of facility:
Date of admission:
Date left home: ______
Please describe your major health problems (if any):
Husband:
Wife:
If not you, who is your “Contact Person” (the person we should contact for appointments, for more information about you, etc.)?:
Do you have any dependents (that is, someone who depends on you, in whole or in part, for their support)?
Yes No If yes, who?:
Are any of your children receiving Supplemental Security Income, Social Security Disability; or, if not, has any major disabilities? Yes No If yes, who?:
II. Resources
Monthly Income
Do not list interest or dividend income.
Source / Husband / WifeSocial Security (gross/net):
Pension (gross/net):
Other (gross/net):
Total:
Real Estate You Own
A. Personal Residence
Address of property:
Names as they appear on deed:
Current Value: Tax-Appraised Value: ______
Mineral Lease No Yes If yes, value: ______
B. Other Real Estate
Address of property:
Names as they appear on deed:
Current Value: Tax-Appraised Value: ______
Mineral Lease No Yes If yes, value: ______
C. Other Real Estate
Business or Farm:
Names as they appear on deed:
Current Value: Tax-Appraised Value: ______
Mineral Lease No Yes If yes, value: ______
Other Assets: Your bank accounts, CDs, annuities, stocks, retirement plans, and the like.
Type of Asset / Company Name / How Is It Titled? / ValueLife Insurance / Policy 1 / Policy 2
Company Name
Owner of Policy
Insured
Beneficiary
Death Benefit (face value)
Current Cash Value (if any)
Loan Against Policy (if any)
Do you have long term care insurance? Yes No
List large items of personal property you own (cars, boats, RVs, farm equipment, livestock, etc.):
Personal Property (Item) / ValueDo you have a prepaid funeral or burial? Yes No
If yes, describe the arrangements:
Have you given away any money or property within the last 60 months? Yes No
If yes, what did you give away and when?
Do you have any of the following documents? / Husband / WifeDurable Power of Attorney / Yes No / Yes No
Medical Power of Attorney / Yes No / Yes No
Living Will / Yes No / Yes No
Will / Yes No / Yes No
Revocable Living Trust / Yes No / Yes No
Please bring the following documents to the meeting, if you have them:
Durable Power of Attorney
Medical Power of Attorney
Living Will
Will
Revocable Living Trust
Last 4 statements on all accounts (checking, savings, securities, IRAs, etc.)
Social Security cards
Medicare/health insurance cards
Proof of income from Social Security or other pensions
Planning Questionnaire- 1 -