Medicaid Planning Survey


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  • CHILDREN:




























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  • ASSETS AND FORM OF OWNERSHIP




















  • IRA's, RETIREMENT ASSETS, 401k's, RETIREMENT PLAN









  • Non Retirement Assets

    All current accounts and accounts closed within 5 years







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  • ANNUITIES







  • LIFE INSURANCE








  • BROKERAGE ACCOUNT

    Those held in past 60 months with a broker. Exclude IRA/ Retirement-type






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  • STOCKS, BONDS, MUTUAL FUNDS






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  • TRANSFERS



    If “yes”. Please fill out form below:



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  • INCOME

    Provide MONTHLY gross amounts
  • FOR APPLICANT
  • FOR SPOUSE
  • ADDITIONAL QUESTIONS: Answer questions about the APPLICANT

































  • ADDITIONAL INFORMATION, COMMENTS, QUESTIONS

  • DOCUMENTS REQUIRED TO DETERMINE MEDICAID ELIGIBILITY
    ** If the applicant is married, all of the documents are needed for BOTH spouses!**

    These are the required documents for your consultation.

    A) Drivers License or State ID card, Social Security card, Medicare card, and Supplemental or Medicare HMO card.

    B) Supplemental Health Insurance Premium Statement: If there is a community spouse the premium statements must reflect how much is being paid by the applicant and how much is being paid by the spouse.

    C) Letter from Social Security. This is a letter from Social Security verifying the amount of the applicant’s Social Security income. It may be obtained online at www.socialsecurity.gov

    D) Verification of date of birth. Birth certificate is usually the best. If birth certificate is not available, written verification of birth date can be obtained upon request from the Social Security Administration.

    E) If applicant is a veteran, please provide VA discharge papers.

    F) If applicant is married, please provide a copy of marriage certificate.

    G) Proof of citizenship. Required only if applicant was born outside the U.S.

    H) Verification of Pension Income. All pension income must be verified from the source. Check stubs are sufficient when they reflect the gross income received. You must provide a letter directly from the pension provider verifying gross, net, and any anticipated changes in the pension (such as whether the pension is fixed or if payment may vary).

    I) Verification of gross monthly income from any other source. (Letter from source required as in “F” above.)

    J) All insurance policies and insurance cards (copies). Life accident, health. If there is a life insurance policy, we have to obtain information as to whether there is cash surrender value, and if so, the amount.

    K) Copies of guardianship or power of attorney papers.

    L) Copy of last will.

    M) Copy of trust.

    N) Income tax returns. Needed for the last five years

    O) Car registration or title, and automobile insurance policy or proof of insurance card.

    P) Copy of deed for any property owed, including homestead and most recent property tax bill

    Q) We will need copies of sold or transferred property from the past five (5) years. Provide copies of all transactional papers, including an appraisal letter from realtor, and the property tax bill which reflects the property’s value at the time of the sale. Also provide photocopy of the most recent property tax bill for all property, including homestead.

    R) Burial arrangements. Copies of any purchase or agreements or any prepaid funeral contracts and/or cemetery or mausoleum plots, etc. All contracts must be irrevocable.

    S) Verification of all active savings accounts, checking accounts, CD’s, stocks, bonds, IRA’s, annuities, etc. Statements are needed for the past 60 months. (Statements are needed for all accounts that have been opened or closed within the last 60 months.) **Also needed are copies of all written checks in the amount of $3,000.00 or more for the past 60 months. If you get a printout from the bank, the printout must be bank stamped, signed and dated. If no bank stamp, please get card from bank personnel attached to printout.

    T) Copy of income trust, if applicable.

    U) Copy of personal services contract, if applicable.

    V) Copy of any Long Term Care policy.

What Our Clients Say

Three gold stars for all of you. You worked hard for us. We really appreciate all you have done for us. We had a lot going on and with your help we finally got it together. You all know what you are doing. Our thanks to all of you.

Past Client

Comprehensive and flexible approach to estate planning. Easy to work with.

C.E.

Kathleen and her team made the process of setting up our wills very easy! Thanks for giving us great peace of mind!

S.C.
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