Website Questionnaire

Name

First

Last

Numbers

What is the name, age, address, phone number and email address of the chronically ill elder?

What is the name, age, address, phone number and email address of his/her spouse if any?

What is the name, age, address, phone number and email address of the chronically ill elder's next of kin?

How much is the chronically ill elder's and his/her spouse's, if any, monthly social security?

How much is the chronically ill elder's and his/her spouse's, if any, monthly pension?

How much is the chronically ill elder's and his/her spouse's, if any, minimum distribution from a pension or IRA?

How much is the chronically ill elder's and his/her spouse's, if any, Veteran's benefits?

Does the chronically ill elder and his/her spouse, if any, have any of the following documents?

Does the chronically ill elder and his/her spouse, if any, have a financial advisor? If so, please provide the name, address, and phone number.

List all health insurance including Medicare, drug plan, private insurance, supplements, HMO’s and long term health insurance for the chronically ill elder his/her spouse, if any.

List the value of each of the assets (including liabilities) of the chronically ill elder , if any, as described below: Indicate if jointly owned and with whom.

Real Estate #1 (Homestead) (chronically ill elder)

List the value of the assets (including liabilities) for the spouse of the chronically ill elder, if any, as described below: Indicate if jointly owned and with whom.

Real Estate #1 (Homestead) (chronically ill elder)

Real Estate #2 (chronically ill elder)

Real Estate #3 (chronically ill elder)

Bank Account #1 (chronically ill elder)

Bank Account #2 (chronically ill elder)

Bank Account #3 (chronically ill elder)

Brokerage Account #1 (chronically ill elder)

Brokerage Account #2 (chronically ill elder)

Individual Retirement Account (chronically ill elder)

401-K, 403-B, Pension (chronically ill elder)

Real Estate #3 (chronically ill elder)

Individual Stocks and Bonds (chronically ill elder)

Mortgages, loans reveivable (chronically ill elder)

Motor Vehicles (chronically ill elder)

Life Insurance (Face Value and Cash Value) (chronically ill elder)

Annuities (chronically ill elder)

Please list all household expenses on a monthly basis as described below:

Mortgage or Rent

Utilities (Water, Electric, Gas)

Real Property Taxes

Property Insurance

Windstorm

Flood

Condo Maintenance

Phone Number

Has the chronically ill person and/or his or her spouse, if any, transferred any assets to anyone else in the last 5 years? If so, when and what?

Website Questionnaire

FAQ QUICK LINKS

MIAMI OFFICE

AVENTURA OFFICE