UNSWORTH LAPLANTE FREE LONG TERM CARE PLANNING FORM

Health Insurance

Total Insurance Cost

Pension

Social Security

Investments

Retirement Accounts

Total Income

Investment/Broker Accounts and Mutual Accounts

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

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

Non-Qualified Annuities: Current value

Real Estate: (residence) per tax bill

Real Estate: (other)

Vehicles: (automobile, motorcycle, boats, etc)

Life Insurance: Cash Value

Personal Property

Prepaid Burial (including head stone and plot)

Other Assets

Total Assets

Rent or Mortgage

Property Taxes

House or Apt. Insurance

Condo/CO-Op Fees

Utilities (ex Gas, Electric, Telephone)

Other Monthly Living Expenses

Total Living Expenses

Loans Payable

Other

Total Amount

Partnership or LLC

Corporation

Other

Total Amount