Income And Asset Worksheet Page 4
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4or do you have a pending lawsuit that may bring property or money to you? If YES, please explain and
bring all records of the payment: ____________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________
VIII. Disabled Children
Yes
No
Does the institutionalized person have a child who is under the age 65 and receiving
disability from Social Security? If so please identify the child and provide a copy of the awards of RSDI
(Social Security) benefits
__________________________________________________________________________________
__________________________________________________________________________________
IX. Documents
We will need the following documents. Please bring them with you to your appointment.
Yes
No
Copy of your and your spouse’s social security card.
Yes
No
Copy of your and your spouse’s drivers license (even if expired).
Yes
No
Copy of your and your spouse’s Medicare card.
Yes
No
Copy of your and your spouse’s health insurance card.
Yes
No
Utility bills for the month of application.
Yes
No
Recent statement of Veteran’s benefits.
Yes
No
Recent statement of Homeowner’s insurance.
Yes
No
Recent mortgage statement.
Yes
No
Recent rent statement for your spouse.
Yes
No
Recent condominium fee statement.
Yes
No
Recent special assessment statement.
Yes
No
Recent tax bills for your and/or your spouse’s home and any other property you and/or
your spouse own.
Yes
No
Recent health insurance premium statement for you and your spouse.
Yes
No
2008 social security benefit letter for you and your spouse.
Yes
No
2008 pension letter for you and/or your spouse or pension check stub.
Yes
No
Copy of any Long Term Care Insurance policies.
Yes
No
Copy of birth certificate, passport, naturalization papers, citizenship papers, or legal
residency documents
*Please keep us current with monthly statements for banks, money market accounts, brokerage
accounts, etc.
Rev Feb. 2008
Page 4 of 4
J. Schuster Certified Elder Law Atty
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