Spousal Financial Data Form
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4SPOUSAL FINANCIAL DATA FORM
RESPONSIBLE PARTY:
Name
S en io r P la n n in g S erv ices
REFERRED TO
Senior Planning Services By:
E sta te P reserv a tio n A n a ly sis
Address
7 4 9 G atew ay S treet, S u ite 2 0 2
A b ilen e, T ex as
7 9 6 0 2
City
Zip
Phone
(3 2 5 ) 6 7 6-5 7 7 5 * (8 0 0 ) 6 7 6 -5 7 7 5
(H)
F A X (3 2 5 ) 6 7 3 -3 1 0 9
(W)
:
E
:_____________________________________
Relationship to applicant
mail Address
In order for Senior Planning Services to conduct a review and analysis of your financial planning profile, and to induce Senior Planning Services to provide an Estate
Preservation Analysis, you agree to provide the information below.
ALL INFORMATION CONTAINED IN THIS APPLICATION WILL BE TREATED CONFIDENTIALLY. However, you agree that Senior Planning Services may
present this document to such parties, as it deems appropriate if called upon to establish that the transactions suggested to you, if effected, were reasonable, lawful and
appropriate. You understand that a false statement by you will constitute a violation of your representations and warranties in this application. You also understand that
Senior Planning Services will rely entirely upon the information provided in this application in making its suggestions to you for Estate Preservation Analysis purposes
and will be under no obligation to conduct any independent investigation or verification of the facts disclosed herein.
You, the undersigned applicant, hereby supply the following information and make the following representations and warranties to Senior Planning Services:
1. Full Name of Applicant:
(Person in or going into Nursing Home)
Male: ______ Female:
__ ____
Substantial Gifts, Loans or Transfers of Money or Property:
______________________________
9. Have you made any substantial gifts, loans or have you transferred
any money or property to anyone in the last 60 months?
Yes
No
Veteran of WWII, Korea, Vietnam, Persian/Gulf
YES____ or NO _____
2. Full Name of Spouse:
If your answer is YES, show the month and year of the gift, loan or
transfer and the amount or value of each.
__________________________________
(Date)
(Circumstances and Value)
Yes
No
Veteran of WWII, Korea, Vietnam, Persian/Gulf
____/____/___ ________________________
____/____/___ ________________________
3.
____/____/___ ________________________
Residence Address and Telephone Number
__________________________________
10. Are you a beneficiary of any trust? YES____ or NO _____
If yes, please describe the terms of the trust, including any rights that you have
__________________________________
to amend or terminate, describe the trust property and its value and identify
who contributed the property to the trust.
Phone: (
)
_____________________________________
_____________________________________
4.
Date of Birth:
Applicant
_____ /_____/_____
_____________________________________
Spouse
_____/_____/_____
11. Has the applicant or the spouse had a Medicaid Assessment done by
the Dept. of Health and Human Services Commission or have they
applied for Medicaid benefits previously?
5.
Marital Status: Married ___ Single ____ Separated ___
YES____ or NO _____
Divorced
Widowed
12. Is the applicant(s) currently in a nursing home?_________
Date of entry into Nursing Facility? ____________________
6.
The applicant supports the following dependents, other than
If No, are you contemplating nursing Facility placement within
your Spouse:
the next few months? _______________________________
Name
Age
Relationship
________________
____________
________________
13 Did the applicant transition directly from a hospital or any
________________
____________
________________
other Medical Care Facility into the Nursing Facility?
YES____ or NO _____ If answered Yes, what was the date of
7.
Name of Power of Attorney:
entry into the hospital or Medical Care Facility
?______________________________________________________
Phone (Work)
14. What is the Medical diagnosis of the applicant?
Phone (Home)
_____________________________________________________
8.
Is there a Guardianship? Yes
No
15. Is the applicant taking Medication for the diagnosis?
YES____ or NO _____
16. Is the applicant capable of medicating himself/herself?
YES____ or NO_____
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