Confidential Three-Year Review Survey

Your Name*
Spouse’s Name, if applicable
Has Your Residence Changed In the Past Three Years? If yes, what is your new mailing address
Describe any significantchanges in health you, your spouse or beneficiaries have experienced
Births? If yes, who?
Deaths? If yes, who?
Divorces?If yes, who?
Marriages?If yes, who?
Are you confident that the following individuals are still ready and willing to serve in the roles you have given them?
Successor Trustee(s)
- Yes
- No
Personal Representative(s)
- Yes
- No
Health Care Surrogate(s)
- Yes
- No
Agent(s) under Durable Power of Attorney
- Yes
- No

Have You Acquired Any Assets Since We Created Your Plan? If yes, please list with approximate value and date acquired

Asset	Value $	Approx Date Acquired

If you have a living trust, are all your assets (including your new assets) titled in the name of the living trust?
- Yes
- No
- Not Sure
Are you concerned about long-term care issues and whether you will need Medicaid?
- Yes
- No
specific concerns would you like to discuss during your consultation?
Your Email*

A copy of this information will be sent to this address.