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 Spouse/Partnerâs Date of Birth MM slash DD slash YYYY Spouse/Partnerâs AgeVeteran 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 InsuranceMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALTotal Insurance CostMedicare PremiumsPerson 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 WagesMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALPensionMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALSocial SecurityMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALInvestmentsMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALRetirement AccountsMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALTotal IncomeMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALASSET INFORMATION AS OF TODAYTYPE OF ASSET Cash, Checking, Savings, CDs, and Money MarketMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALInvestment/Broker Accounts and Mutual AccountsMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALRetirement Accounts (IRA, 401K, 403B, SEP, qualified annuities)Medicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALStocks or bonds (you hold, not in brokerage accounts)Medicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALNon-Qualified Annuities: Current valueMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALReal Estate: (residence) per tax bill Medicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALReal Estate: (other)Medicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALVehicles: (automobile, motorcycle, boats, etc) Medicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALLife Insurance: Cash ValueMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALPersonal PropertyMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALPrepaid Burial (including head stone and plot) Medicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALOther AssetsMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALTotal AssetsMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTAL MONTHLY LIVING EXPENSESSource Medical expensesMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALRent or MortgageMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALProperty TaxesMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALHouse or Apt. InsuranceMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALCondo/CO-Op FeesMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALUtilities (ex Gas, Electric, Telephone)Medicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALOther Monthly Living ExpensesMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALTotal Living ExpensesMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALAMOUNT OF LIABILITIES (NOT MONTHLY)TYPE MortgageMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALLoans PayableMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALOtherMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALTotal AmountMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALBUSINESS INTERESTSTYPE FarmMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALPartnership or LLCMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALCorporationMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALOtherMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALTotal AmountMedicare PremiumsPerson Considering eligibilitySPOUSEJOINTTOTALOther things you think we should know: Δ
