CONFIDENTIAL LONG TERM CARE PLANNING SURVEY

Note: If applicant is married, information is required for applicant & spouse We recognize that this information is of a personal nature. All information provided to us by you will be treated confidentially and not revealed to anyone outside this office without your permission.
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SECTION 1: GENERAL INFORMATION
Name of Applicant*
Home Address or Nursing Home Address
City
State
Zip
If in nursing home, date of admission
Month
Day
Year
Date of Birth
Month
Day
Year
Spouse Information, if applicable:
Name
Date of Marriage
Month
Day
Year
Date of Birth
Month
Day
Year
Soc Sec #
If Deceased, Date of Death
Month
Day
Year
Home Phone
Work Phone
Cell Phone
Email*
Alternate/2nd Street Address
City
State
Zip
Alternate Home Phone Number
Name of Person/Company who referred you to this firm
May we thank the referral person?
- Yes
- No
Name, Address & Tel. No. of person filling out this form (if other than client)

Children of Applicant & Spouse (include children from prior marriages, if any):
Name
Date of birth
Month
Day
Year
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
Name
Date of birth
Month
Day
Year
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
Name
Date of birth
Month
Day
Year
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
Name
Date of birth
Month
Day
Year
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
Name
Date of birth
Month
Day
Year
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
Additional children or friends/relatives/others assisting in the long-term care planning process (attach additional sheet if more room needed)
Name
Relationship to Applicant
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
Name
Relationship to Applicant
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email

Bank Name	Acct #	Account Type (Checking / Savings / CD)	Owner (Applicant / Spouse / Trust / Applicant & Spouse / Applicant & Other / Spouse & Other)	Approx Value $	If closed, date closed

Bank or Brokerage	Owner (Husband / Spouse)	Name of Beneficiary	Approx Value $

Company	Policy #	Approx Value $	Owner (Applicant / Spouse / Applicant & Spouse / Applicant & Other / Spouse & Other / Trust)	Annuitant Name

Company	Policy #	Owner (Applicant / Spouse / Trust)	Name of Insured	Face Value $	Cash Surrender Value $

Broker Name	Acct #	Owner (Applicant / Spouse / Trust / Applicant & Spouse / Applicant & Other / Spouse & Other)	Approx Value $	If closed, date closed

SECTION 1: GENERAL INFORMATION

Stock/Bond/Mutual Fund	Owner (Applicant / Spouse / Trust / Applicant & Spouse / Applicant & Other / Spouse & Other)	Approx Value $	If closed, date closed

Name of Borrower	Owner (Applicant / Spouse / Trust / Applicant & Spouse)	Approx Value $

Type of Property/Asset	Value $	Type of Transfer (Gift / Sale)	Date of Transfer

Applicant / Spouse	Soc Sec/Month $	Pension/Month $	Veterans Benefits/Month $	Other Income/Month $