Financial Questionnaire

Client Name
Marital Status: (M/S/W/D)
Facility Name
Date of Admission
MM slash DD slash YYYY
Medicare #
Client D/O/B
MM slash DD slash YYYY
Client's Home Address
Spouse Name
Spouse DOB
MM slash DD slash YYYY
Are you a Veteran or a spouse of a Veteran?
- Yes
- No
Need to Apply for VA benefits?
- Yes
- No
Spouse Medicare #
Family/POA
Phone
Email
Family/POA
Phone
Email
Income
Social Security $
Spouse $
Pensions $
Company Name
Company Name
Dividends & Interest $
Type
Income from Annuities $
Type
Rent from Real Estate $
Type
VA income $
Type
Other Income $
Type
Gross Total Income: $
Assets
Investments/Retirement Accounts

List all investment/retirement accounts (including but not limited to stocks, bonds, mutual funds, etc.)
Name of Investment/Brokerage Company
Current Balance: $
Name of Investment/Brokerage Company
Current Balance: $
Gross Total Assets: $
Bank Accounts

List all current bank accounts (including but not limited to checking, savings, CD’s, Money Markets, etc.). List any closed account within the last 12 months.
Name of Bank
Type
Account Owner(s)
Current Balance: $
Name of Bank
Type
Account Owner(s)
Current Balance: $
Name of Bank
Type
Account Owner(s)
Current Balance: $
Have you closed any bank accounts in the last 60 months
- Yes
- No
If yes, please describe where assets were transferred
Life Insurance
Name of Insurance Company
Policy #
Face Value
Cash Surrender Value
Name of Insurance Company
Policy #
Face Value
Cash Surrender Value
Have you liquidated any insurance policies within the last 60 months?
- Yes
- No
If yes, please describe where assets were transferred
Real Estate Property
Do you own your own home
- Yes
- No
Current, Appraised or Estimated Value $
Do you own any rental property
- Yes
- No
Current, Appraised or Estimated Value $
Do you own any other real property
- Yes
- No
Current, Appraised or Estimated Value $
Lawyer Consultation Needed for
- QIT
- PSA
- DEED
- Spousal Refusal
Burial Accounts
Name of Funeral Home
Is policy Irrevocable
- Yes
- No
Automobiles
Year
Make
Model
Year
Make
Model
Please answer the following questions:
Are any assets held in trust
- Yes
- No
If yes, please supply a copy of the trust
Have any assets/cash/property been sold/ transferred/gifted in the last 60 months
- Yes
- No
If yes, please describe below

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