Client Bill Pay Assistance Intake Form

Client Bill Pay Assistance Intake Form

*Note: Questions with an asterisk (*) are required.

Name

First NameMiddle NameLast Name

Date of Birth

Date

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list all monthly bills/expenses:

Rows	Description	Monthly Amount	Auto-Pay (Yes/No)	Notes
Housing
Utilities
Insurance
Medical
Dental
Personal
Other

Please list all sources of monthly income:

Rows	Monthly Amount	Notes
Social Security
Pension
Employment
Annuity
Other

Please list all assets:

Rows	Bank Name	Last 4 Digits of Account Number	Notes
Checking
Savings
Money Market
CDs
Investments
Joint Account
Other

List all accounts to be used for bill payments:

Rows	Bank Name	Account Type	Last 4 Digits of Account Number	Notes
1
2
3
4
5

What type of assistance is needed? (Check all that apply)

Please select the frequency of desired services:

Please select your preferred payment method:

Please select your preferred format for records:

Please select your preferred method of communication:

Please list All Emergency/Professional Contacts

Rows	Name	Phone Number	Email
Primary Contact
Trusted Family Member
Power of Attorney
Attorney
Financial Advisor
CPA

Additional Comments:

Elder Law Collaborative, LLC is granted permission to (select all that apply):

DISCLAIMER AND AUTHORIZATION: By signing below, I acknowledge and understand that bill pay assistance services are strictly administrative in nature and do not constitute any financial, legal or investment advice. I authorize Elder Care Collaborative, LLC to perform the services selected above and grant permission to access my financial records as necessary to complete such services.

Please submit all applicable statements below:

Browse Files

Sheri L. Montecalvo, Esq.

272 West Exchange Street, Suite 001

Providence, RI 02903

401-600-0157 (office)

401-300-1429 (cell)

401-453-0073 (fax)

sheri.montecalvo@elderlawcollaborative.com