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Unsworth LaPlante, PLLC

Vermont Estate Planning Attorneys

Vermont: (802) 879-7133

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Home Âğ UNSWORTH LAPLANTE FREE LONG TERM CARE PLANNING FORM

UNSWORTH LAPLANTE FREE LONG TERM CARE PLANNING FORM

MM slash DD slash YYYY
I am completing this form for:

Person/People considering Long Term Care:

Martial Status
MM slash DD slash YYYY
Veteran
U.S. Citizen
1 st Marriage:
MM slash DD slash YYYY
Veteran
U.S. Citizen
1 st Marriage:
Your - Current Health
Spouse/Partner - Current Health
Have you given away any assets in the last 60 Months?
MM slash DD slash YYYY

MONTHLY HEALTH INSURANCE EXPENSES

Source

Medicare Premiums

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Health Insurance

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Total Insurance Cost

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

LONG-TERM CARE INSURANCE

Do you have Long-term Care Insurance?
Does your Spouse/Partner

MONTHLY INCOME

Source

Wages

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Pension

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Social Security

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Investments

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Retirement Accounts

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Total Income

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

ASSET INFORMATION AS OF TODAY

TYPE OF ASSET

Cash, Checking, Savings, CDs, and Money Market

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Investment/Broker Accounts and Mutual Accounts

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Retirement Accounts (IRA, 401K, 403B, SEP, qualified annuities)

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Stocks or bonds (you hold, not in brokerage accounts)

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Non-Qualified Annuities: Current value

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Real Estate: (residence) per tax bill

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Real Estate: (other)

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Vehicles: (automobile, motorcycle, boats, etc)

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Life Insurance: Cash Value

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Personal Property

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Prepaid Burial (including head stone and plot)

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Other Assets

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Total Assets

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

MONTHLY LIVING EXPENSES

Source

Medical expenses

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Rent or Mortgage

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Property Taxes

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

House or Apt. Insurance

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Condo/CO-Op Fees

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Utilities (ex Gas, Electric, Telephone)

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Other Monthly Living Expenses

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Total Living Expenses

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

AMOUNT OF LIABILITIES (NOT MONTHLY)

TYPE

Mortgage

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Loans Payable

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Other

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Total Amount

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

BUSINESS INTERESTS

TYPE

Farm

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Partnership or LLC

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Corporation

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Other

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

Total Amount

Medicare Premiums
Person Considering eligibility
SPOUSE
JOINT
TOTAL

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