Benefits Planning Questionnaire


This questionnaire is designed to help us gather the information needed to create a plan to protect your assets (or the assets of your family member or friend). This questionnaire is essential to our understanding of your case. Please complete it with as much detail as possible.

*Information is needed for each spouse in every instance unless otherwise specified.

Preferred Method of Contact for Correspondence and/or Billing*
Date/Time

Section 1: Name and Contact Information

Person Completing Form:*
Gender*
Home Address:
Client's Full Name: (Person Applying for Medicaid)
Gender - Client*
Client's Spouse Full Name:
Home Address:
Client's Marital Status:
Is the Client a U.S. Citizen?
Is the Spouse a U.S. Citizen?

Section 2: Facility

Is Client currently in a facility?
Facility Address:
Name, email, phone
Name, email, phone
Name, email, phone
Is Spouse currently in a facility?
Facility Address:
Name, email, phone
Name, email, phone
Name, email, phone

Section 3: Children


List ALL children belonging to each spouse.

Copy and attach additional pages, if needed.

Do all the children and/or step-children have a good relationship with each other?
Do all the children/step-children have a good relationship with the client and spouse?
Do any of the children and/or step-children have any objections to Medicaid Planning or a spend-down of assets?
Name of Child:
Parent:
Disabled?
Name of Child's Spouse:
Current Address:
Name of Child:
Parent:
Disabled?
Name of Child's Spouse:
Current Address:
Parent
Disabled?
Current Address:
Parent:
Disabled?
Current Address:
Parent:
Disabled?
Current Address:
No File Chosen
File uploads may not work on some mobile devices.

Section 4: Estate Planning and Other Documents


Please provide a copy of each document.

Client Last Will and Testament:
Spouse Last Will and Testament:
Client Revocable Living Trust:
Spouse Revocable Living Trust:
Client Durable Power of Attorney:
Spouse Durable Power of Attorney:
Client Health Care Surrogate:
Spouse Health Care Surrogate:
Client Living Will:
Spouse Living Will:
No File Chosen
File uploads may not work on some mobile devices.

Section 5: Transfers To or From Trusts

Has the person needing care (or his/her spouse) transferred property into a Trust or out of a Trust (revocable or irrevocable) within the past 60 months?*

Please provide the following information.

$

Section 6: Income


Gross Monthly Income

(List gross income amounts before deductions for each spouse.)

i.e. Social Security, Pension, Annuity, VA Aid & Attendance, etc.
i.e. Social Security, Pension, Annuity, VA Aid & Attendance, etc.
i.e. Social Security, Pension, Annuity, VA Aid & Attendance, etc.
i.e. Social Security, Pension, Annuity, VA Aid & Attendance, etc.
i.e. Social Security, Pension, Annuity, VA Aid & Attendance, etc.
No File Chosen
File uploads may not work on some mobile devices.

Section 7: Health Insurance


For each spouse

Does person needing care have private health insurance or are they paying for a Medicare supplement policy?*

(For each spouse) please provide the following information:

i.e. Acme Insurance
i.e. 123-45-6789
i.e. Supplemental
i.e. $250.00
i.e. Acme Insurance
i.e. 123-45-6789
i.e. Supplemental
i.e. $250.00
i.e. Acme Insurance
i.e. 123-45-6789
i.e. Supplemental
i.e. $250.00
i.e. Acme Insurance
i.e. 123-45-6789
i.e. Supplemental
i.e. $250.00

Section 8: Long-Term Care Insurance

Does the client or spouse have long-term care insurance?*

Please provide the following information for each spouse’s policy:

i.e. Acme Insurance, Long-term care
i.e. 123-45-6789
i.e. $500.00
i.e. $100.00
i.e. Acme Insurance, Long-term care
i.e. 123-45-6789
i.e. $500.00
i.e. $100.00
i.e. Acme Insurance, Long-term care
i.e. 123-45-6789
i.e. $500.00
i.e. $100.00
How does the policy pay?

Section 9: Assets and Resources


(All accounts jointly or individually owned by each spouse, including those with third-party co-owners)

A. Cash and Bank Accounts (CDs, Checking, Savings, etc.)

i.e. Big Bank/Main St.
i.e. Sole ownership or jointly with son
Do you have another account to add?
i.e. Sole ownership or jointly with son
Do you have another account to add?
i.e. Sole ownership or jointly with son
Do you have another account to add?
i.e. Sole ownership or jointly with son

B. Retirement Accounts (IRAs, 401Ks, Roth Accounts, Keough plans, 403(b) plans, etc.) (For both spouses)

i.e. Big Broker
i.e. Client
i.e. Spouse
i.e. January 1970
i.e. $XX,XXX
Do you have another account to add?
i.e. Big Broker
i.e. Client
i.e. Spouse
i.e. January 1970
i.e. $XX,XXX
Do you have another account to add?
i.e. Big Broker
i.e. Client
i.e. Spouse
i.e. January 1970
i.e. $XX,XXX
Do you have another account to add?
i.e. Big Broker
i.e. Client
i.e. Spouse
i.e. January 1970
i.e. $XX,XXX

C. Annuities (For both spouses)

i.e. Company Name
i.e. Client
i.e. Spouse
i.e. January 1970
i.e. $XX,XXX
Do you have another account to add?
i.e. Company Name
i.e. Client
i.e. Spouse
i.e. January 1970
i.e. $XX,XXX
Do you have another account to add?
i.e. Company Name
i.e. Client
i.e. Spouse
i.e. January 1970
i.e. $XX,XXX

Section 10: Life Insurance

List all life insurance policies owned by either spouse

i.e. Acme Insurance
i.e. Client
i.e. $100
i.e. $10,000
Do you have another policy to add?
i.e. Acme Insurance
i.e. Client
i.e. $100
i.e. $10,000
Do you have another policy to add?
i.e. Acme Insurance
i.e. Client
i.e. $100
i.e. $10,000

Section 11: Residence (Homestead) - IF OWNED

A. Address:
E. Is there a Reverse Mortgage?
F. Is there lot rent?

Residence

Do you own or rent your home?*

Section 12: Rental

Rental/Lease Agreement

Section 13: Monthly Housing Expenses

A. Housing (Estimated per Month)

Section 14: All Non-Homestead Property

Do you or your spouse have any other property jointly or individually owned, including those with third-party co-owners?*

Please list:

A. Address:
E. Currently being rented?

Additional Non-Homestead Property #2


(All property jointly or individually owned by each spouse, including those with third-party co-owners)

A. Address:
E. Currently being rented?

Section 15: Vehicles

Do you or your spouse own any vehicles, including cars, trucks, motorcycles, recreational vehicles, boats, campers?*


List all vehicles owned by the client or spouse, including cars, trucks, motorcycles, recreational vehicles, boats, campers.

Do you have another vehicle to add?
Do you have another vehicle to add?

Section 16: Burial/Funeral Arrangements


Under the Medicaid rules, certain items are "exempt" from consideration as an available asset to pay for long-term care. Some of those items are listed below. Please indicate whether the person needing care has the listed items.

Client Burial Plot:
Spouse Burial Plot:
Client Burial Fund Contract:
Spouse Burial Fund Contract:

Section 17: Transfers of Assets Within the Last 60 Months

Has the client or spouse transferred any assets or property to someone within the past 60 months? Transfers also include any financial assistance to anyone, including loans, paying someone's bills and/or living expenses, plus gifts of case or assets.*

Please describe below.

Section 18: Closed Accounts or Sold Assets Within the Last 60 Months

Has the client or spouse closed an account or sold an asset within the past 60 months?*

Please describe below.

i.e. Bank Name
i.e. Checking
i.e. $500
i.e. Other bank #12345
Do you have another account to add?
i.e. Bank Name
i.e. Checking
i.e. $500
i.e. Other bank #12345
Do you have another account to add?
i.e. Bank Name
i.e. Checking
i.e. $500
i.e. Other bank #12345
Do you have another account to add?
i.e. Bank Name
i.e. Checking
i.e. $500
i.e. Other bank #12345

Section 19: Debt


Enter the outstanding balance of debt of each spouse.

i.e. Credit card
i.e. John and Jane's
i.e. US Bank
Do you have more debt to add?
i.e. Credit card
i.e. US Bank
Do you have more debt to add?
i.e. Credit card
i.e. US Bank
Do you have more debt to add?
i.e. Credit card
i.e. US Bank

Section 20: Other Information

Do you or your spouse have any other personal property of high value?*

A. Please list.

i.e. Jewels, furs, art, etc.
i.e. Jewels, furs, art, etc.
i.e. Jewels, furs, art, etc.
i.e. Jewels, furs, art, etc.
Do you or your spouse have any other business interests to list?*

B. Please list any business interests (for each spouse).

C. Rights or Interests in Trusts, Estates, or Prospective Inheritances (for each spouse)

No File Chosen
File uploads may not work on some mobile devices.

D. Safe Deposit Box

Do you or your spouse have a safe deposit box?*

PLEASE READ AND SIGN BELOW.

I understand that it is my responsibility to disclose correct and complete information concerning the applicant's and the spouse's financial assets, income, and personal circumstances that relate to eligibility for Medicaid or VA benefits. I hereby attest that the information I have supplied is complete and accurate to the best of my knowledge.

I realize that any changes in the applicant's circumstances that might affect Medicaid or VA benefit eligibilty must be reported as soon as possible. I will disclose new or previously undiscovered assets as it becomes known to me. I acknowledge that any undisclosed or later discoverd income or assets may result in delayed planning, additional planning costs or Medicad benefits denial.

Use your mouse or finger to draw your signature above
Name:*
Date:*
Save and Resume Later
Progress