UNSWORTH LAPLANTE FREE LONG TERM CARE PLANNING FORM Date MM slash DD slash YYYY I am completing this form for: Myself Parent Other My name is My name is Person/People considering Long Term Care:Martial Status Married Single Widowed Name(Required) Date of Birth(Required) MM slash DD slash YYYY Number(Required)Veteran Veteran U.S. Citizen U.S. Citizen 1 st Marriage: Yes No Spouse/Partnerâs Name(Required) Spouse/Partnerâs Date of Birth(Required) MM slash DD slash YYYY Spouse/Partnerâs Age(Required)Veteran Veteran U.S. Citizen U.S. Citizen 1 st Marriage: Yes No Your - Current Health Good Concern Problem Details Details Spouse/Partner - Current Health Good Concern Problem Details Details Have you given away any assets in the last 60 Months? No Yes (please answer following questions) Total Value GivenWhat Date was the gift given MM slash DD slash YYYY MONTHLY HEALTH INSURANCE EXPENSESSource Medicare PremiumsMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALHealth InsuranceHealth InsurancePerson Considering eligibilitySPOUSEJOINTTOTALTotal Insurance CostTotal Insurance CostPerson Considering eligibilitySPOUSEJOINTTOTALLONG-TERM CARE INSURANCEDo you have Long-term Care Insurance? Yes No Does your Spouse/Partner Yes No Daily Benefit:Term (in months)Monthly Cost:MONTHLY INCOMESource WagesWagesPerson Considering eligibilitySPOUSEJOINTTOTALPensionPensionPerson Considering eligibilitySPOUSEJOINTTOTALSocial SecuritySocial SecurityPerson Considering eligibilitySPOUSEJOINTTOTALInvestmentsInvestmentsPerson Considering eligibilitySPOUSEJOINTTOTALRetirement AccountsRetirement AccountsPerson Considering eligibilitySPOUSEJOINTTOTALTotal IncomeTotal IncomePerson Considering eligibilitySPOUSEJOINTTOTALASSET INFORMATION AS OF TODAYTYPE OF ASSET Cash, Checking, Savings, CDs, and Money MarketCash, Checking, Savings, CDs, and Money MarketPerson Considering eligibilitySPOUSEJOINTTOTALInvestment/Broker Accounts and Mutual AccountsInvestment/Broker Accounts and Mutual AccountsPerson Considering eligibilitySPOUSEJOINTTOTALRetirement Accounts (IRA, 401K, 403B, SEP, qualified annuities)Retirement Accounts (IRA, 401K, 403B, SEP, qualified annuities)Person Considering eligibilitySPOUSEJOINTTOTALStocks or bonds (you hold, not in brokerage accounts)Stocks or bonds (you hold, not in brokerage accounts)Person Considering eligibilitySPOUSEJOINTTOTALNon-Qualified Annuities: Current valueNon-Qualified Annuities: Current valuePerson Considering eligibilitySPOUSEJOINTTOTALReal Estate: (residence) per tax bill Real Estate: (residence) per tax billPerson Considering eligibilitySPOUSEJOINTTOTALReal Estate: (other)Real Estate: (other)Person Considering eligibilitySPOUSEJOINTTOTALVehicles: (automobile, motorcycle, boats, etc) Vehicles: (automobile, motorcycle, boats, etc)Person Considering eligibilitySPOUSEJOINTTOTALLife Insurance: Cash ValueLife Insurance: Cash ValuePerson Considering eligibilitySPOUSEJOINTTOTALPersonal PropertyPersonal PropertyPerson Considering eligibilitySPOUSEJOINTTOTALPrepaid Burial (including head stone and plot) Prepaid Burial (including head stone and plot)Person Considering eligibilitySPOUSEJOINTTOTALOther AssetsOther AssetsPerson Considering eligibilitySPOUSEJOINTTOTALTotal AssetsTotal AssetsPerson Considering eligibilitySPOUSEJOINTTOTAL MONTHLY LIVING EXPENSESSource Medical expensesMedical expensesPerson Considering eligibilitySPOUSEJOINTTOTALRent or MortgageRent or MortgagePerson Considering eligibilitySPOUSEJOINTTOTALProperty TaxesProperty TaxesPerson Considering eligibilitySPOUSEJOINTTOTALHouse or Apt. InsuranceHouse or Apt. InsurancePerson Considering eligibilitySPOUSEJOINTTOTALCondo/CO-Op FeesCondo/CO-Op FeesPerson Considering eligibilitySPOUSEJOINTTOTALUtilities (ex Gas, Electric, Telephone)Utilities (ex Gas, Electric, Telephone)Person Considering eligibilitySPOUSEJOINTTOTALOther Monthly Living ExpensesOther Monthly Living ExpensesPerson Considering eligibilitySPOUSEJOINTTOTALTotal Living ExpensesTotal Living ExpensesPerson Considering eligibilitySPOUSEJOINTTOTALAMOUNT OF LIABILITIES (NOT MONTHLY)TYPE MortgageMortgagePerson Considering eligibilitySPOUSEJOINTTOTALLoans PayableLoans PayablePerson Considering eligibilitySPOUSEJOINTTOTALOtherOtherPerson Considering eligibilitySPOUSEJOINTTOTALTotal AmountTotal AmountPerson Considering eligibilitySPOUSEJOINTTOTALBUSINESS INTERESTSTYPE FarmFarmPerson Considering eligibilitySPOUSEJOINTTOTALPartnership or LLCPartnership or LLCPerson Considering eligibilitySPOUSEJOINTTOTALCorporationCorporationPerson Considering eligibilitySPOUSEJOINTTOTALOtherOtherPerson Considering eligibilitySPOUSEJOINTTOTALTotal AmountTotal AmountPerson Considering eligibilitySPOUSEJOINTTOTALOther things you think we should know: Δ
