LTC Worksheet

Today's Date*

Your Full Name*

Prefix First Middle Last Suffix

Client - Income

Monthly Income - (Please list description and amount):

SSA Income:

Monthly Earnings (Please also list type):

Monthly Pension:

Other Monthly Income (IRA Withdrawals, etc.):

Other Monthly Income (Please list source):

Cost of Care

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

Medical Insurance Premium:

Long-Term Care Premium:

Monthly Cost of Care:

Other Costs

Other Costs (Please list description and amount):

Mortgage/Rent

Home Maintenance

Utilities

Food

Transportation

Personal Care

Entertainment/Food/Clothing (Cash-flow/mo.)

Assets

Assets (Please list description and amount / Date of Stmt.):

Real Property - Primary Residence:

Real Property - Other Residence:

Long-Term Care Policy

Investment Accounts (IRA, Mutual Fund, Etc.):

Other Assets:

Family & Possible Beneficiaries

Names of all Children / Grandchildren / Any Other Named Beneficiaries (Please Include Birth Dates & Marital Status):

* 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.

Phone

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