Long-Term Care Planning Questionnaire

This questionnaire is designed to help us gather the information necessary to properly plan to protect your assets (or the assets of a family member or friend) during a time when there may be a need for Long-Term Care. Whether you are a new or an established client, we have found this questionnaire extremely helpful and we ask your indulgence in completing it fully. Those questions that do not apply to you, your family, or your financial situation may simply be ignored. Please feel free to provide other information you feel is relevant.

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Today's Date

MonthDayYear
Date
Section 1. Name and Contact Information
Person Completing Form

First NameMiddle NameLast Name
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Client:
Client's Full Name

First NameMiddle NameLast Name
Spouse's Full Name

First NameMiddle NameLast Name
Client's Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number (Home):
Please enter a valid phone number.
Spouse Phone Number (Home):
Please enter a valid phone number.
Client Phone Number (Cell)
Please enter a valid phone number.
Spouse Phone Number (Cell)
Please enter a valid phone number.
Client Date of Birth:
Spouse Date of Birth:
Client Former/Maiden Names:
Spouse Former/Maiden Names:
Client US Citizen?

YesNo
Spouse US Citizen?

YesNo
Client Military Service:

YesNo
Spouse Military Service:

YesNo
Client Social Security Number:
Spouse Social Security Number:
Client Military Service:
Spouse Military Service:
Client Date of Death (or N/A):
Spouse Date of Death (or N/A):

Section 2. Marital Information
A. Date of Marriage
B. Place of Marriage (City, State or Province, Country)
C. Client's Former Spouses:
1. Name of Former Spouse

First NameLast Name
Date of Marriage

MonthDayYear
Date
Place of Marriage
Year Terminated
How Terminated
Still Living?
If still loving, describe relationship
2. Name of Former Spouse

First NameLast Name
Date of Marriage

MonthDayYear
Date
Place of Marriage
Year Terminated
How Terminated
Still Living?
If still loving, describe relationship
3. Name of Former Spouse

First NameLast Name
Date of Marriage

MonthDayYear
Date
Place of Marriage
Year Terminated
How Terminated
Still Living?
If still loving, describe relationship
C. Spouse's Former Spouses:
1. Name of Former Spouse

First NameLast Name
Date of Marriage

MonthDayYear
Date
Place of Marriage
Year Terminated
How Terminated
Still Living?
If still loving, describe relationship
2. Name of Former Spouse

First NameLast Name
Date of Marriage

MonthDayYear
Date
Place of Marriage
Year Terminated
How Terminated
Still Living?
If still loving, describe relationship
3. Name of Former Spouse

First NameLast Name
Date of Marriage

MonthDayYear
Date
Place of Marriage
Year Terminated
If still loving, describe relationship
How Terminated
Still Living?

Section 4: Asset/Liability Information

Please list your asset/liability information in the appropriate category below. Attach a separate page if necessary. While exact amounts are not necessary, a realistic estimate for each account is required to provide us with the information required to make the proper recommendations.
Real Estate

Include address. Bring deed and tax bill if considering Medicaid planning.
Personal Residence
Title in Which Held
Type of Property
Current Value
Vacant Land Residence
Title in Which Held
Type of Property
Current Value
Other Property
Title in Which Held
Type of Property
Current Value
Liquid Assets
Cash on Hand
Financial Institution
Checking Accounts
Financial Institution
Saving Accounts
Financial Institution
Other Asset Types
Certificates of Deposit: Title in Which Held
Certificates of Deposit Current Value
Brokerage/Stocks/Securities
Brokerage/Stocks/Securities Current Value
Equity in Business
Equity in Business Title in Which Held
Equity in Business Current Value
Notes and Loans Receivable
Notes and Loans Receivable Current Value
Pensions/Profit Sharing
Pension/Profit Sharing Current Value
Life Insurance
Life Insurance Current Value
Life Insurance Death Benefit
Retirement Accounts, IRAs,401(k)s, 403(b)s, DeferredCompensation
Current Value
Other Assets
1 - Liabilities
Name Loan Taken In
Amount Owed
2- Liabilities
Name Loan Taken In
Amount Owed
3 - Liabilities
Name Loan Taken In
Amount Owed

Section 6: Fiduciaries

Please consider the who you want to handle your affairs when you cannot. We will discuss this section at our conference and will assist you with the completion.
A. Executors
1. Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
2. Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

B. Guardians of Minor Children
Co-Guardians Act:
1. Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Co-Guardian with Previous Name (May surviving Co-Guardian act alone?
2. Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

C. Agents Under Power of Attorney
Co-Agents Act:
1. Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

D. Agents Under Health Care Power of Attorney
Phone Number
Please enter a valid phone number.
1. Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
2. Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

Please feel free to provide other information you feel is relevant.
Should be Empty:

Section 1. Name and Contact Information

Section 2. Marital Information

C. Client's Former Spouses:

C. Spouse's Former Spouses:

Section 3: Children:

Section 4: Asset/Liability Information

Real Estate

Personal Residence

Vacant Land Residence

Other Property

Liquid Assets

Other Asset Types

Other Assets

Section 5: Dispositive Planning

Section 6: Fiduciaries

B. Guardians of Minor Children

C. Agents Under Power of Attorney

D. Agents Under Health Care Power of Attorney