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Income, Assets & Expenses Worksheet (Married)
Income, Assets & Expenses Worksheet (LTC Planning)
Today's Date
*
Date Format: MM slash DD slash YYYY
Your Full Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
Client #1 - Income
Monthly Income - (Please list description and amount):
Client #1 - SSA Income:
Client #1 - Monthly Earnings (Please also list type):
Client #1 - Monthly Pension:
Client #1 - Other Monthly Income (IRA Withdrawals, etc.):
Client #1 - Other Monthly Income (Please list source):
Client #1 - Cost of Care
Cost of Care - (Please list description and amount):
Client #1 - Medical Insurance Premium:
Client #1 - Long-Term Care Premium:
Client #1 - Monthly Cost of Care:
Client #1 - Other Costs
Other Costs (Please list description and amount):
Client #1 - Mortgage/Rent
Client #1 - Home Maintenance
Client #1 - Utilities
Client #1 - Food
Client #1 - Transportation
Client #1 - Personal Care
Client #1 - Entertainment/Food/Clothing (Cash-flow/mo.)
Client #1 - Assets
Assets (Please list description and amount / Date of Stmt.):
Client #1 - Real Property - Primary Residence:
Client #1 - Real Property - Other Residence:
Client #1 - Long-Term Care Policy
Client #1 - Investment Accounts (IRA, Mutual Fund, Etc.):
Client #1 - Other Assets:
Client #2 - Income
Monthly Income - (Please list description and amount):
Client #2 - SSA Income:
Client #2 - Monthly Earnings (Please also list type):
Client #2 - Monthly Pension:
Client #2 - Other Monthly Income (IRA Withdrawals, etc.):
Client #2 - Cost of Care
Cost of Care - (Please list description and amount):
Client #2 - Medical Insurance Premium:
Client #2 - Long-Term Care Premium:
Client #2 - Monthly Cost of Care:
Client #2 - Other Costs
Other Costs (Please list description and amount):
Client #2 - Mortgage/Rent
Client #2 - Home Maintenance
Client #2 - Utilities
Client #2 - Food
Client #2 - Transportation
Client #2 - Personal Care
Client #2 - Entertainment/Food/Clothing (Cash-flow/mo.)
Client #2 - Assets
Client #2 - Real Property - Primary Residence:
Client #2 - Real Property - Other Residence:
Client #2 - Long-Term Care Policy
Client #2 - Investment Accounts (IRA, Mutual Fund, Etc.):
Client #2 - 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.
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