• Client - Income

  • Monthly Income - (Please list description and amount):
  • Cost of Care

  • Cost of Care - (Please list description and amount):
  • Other Costs

  • Other Costs (Please list description and amount):
  • Assets

  • Assets (Please list description and amount / Date of Stmt.):
  • Family & Possible Beneficiaries

  • * In preparation for your upcoming consultation, please complete the following application as completely as possible. Since your time together over the phone is limited, having this information prepared prior to your consultation will allow Ms. Amrine to make the best use of your time and evaluate your situation. Please also email/upload copies of any of the additional items listed below that you may have : - Latest bank/investment statements - Copy of deed to real property (or property tax bill) - If applicable, Military discharge papers (DD-214) - Any life or long term care insurance policies, - Current Estate Plan Documents *In-Person Consultation Only: If you do not have access/ability to scan and email these documents prior to your consultation, please prepare and bring copies of your documents to our office.
  • This field is for validation purposes and should be left unchanged.