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We take an uncommon satisfaction in helping people make difficult decisions that are good for them. Confidential Worksheet for
_____________________________________________ and ______________________________________ Name
Name
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Common Sense Companies
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[Type text] Common Sense Companies www.Commonsensecompanies.com Confidential
Personal Information
Client Name
Spouse Name
Questions/Goals
√ Check all that apply and we will get you the information at no cost.
Determine if we can afford long-term care protection
Information on long term care where our premiums get returned if I (we) never make a claim?
Information on IRAs and 401K rollovers
Assistance in qualifying for VA Aid & Attendance benefits to pay for all forms of care.
Find out how much of our assets can be protected or saved by pre-planning for Medicaid.
Help setting aside guaranteed money to pay for funeral expenses.
Determine if I (we) need to continue paying life insurance premiums.
Protect assets from lawsuits, creditors, or from liens.
Protect assets for my/our children to receive after I/we pass on.
Help avoiding going through probate
Safest methods of passing assets on, tax tree
Do you have children or grandchildren for whom you would like to set up a college tuition fund
at no out-of-pocket money from you?
Other
Please return to: Cell: Fax: Email: Common Sense Companies www.commonsensecompanies.com Confidential
Personal Information
Client Name
Spouse Name
Client Date of Birth
Spouse Date of Birth
Client Cell Phone
Spouse Cell Phone
Home Phone
Home Address
City
State/Zip
Veteran Yes
No
Veteran Yes
No
Health Questions
Client
Spouse
Please circle or underline all conditions that apply.
Have you ever had, do you currently have, have you been medically diagnosed as
having or have you been treated for Stroke/TIA (within the last 5 years), multiple
strokes/TIAs, stroke with residual impairment; Alzheimer’s disease;
dementia/organic brain syndrome, memory loss and/or persistent forgetfulness that
is progressive or treated with prescription medication; mental retardation;
schizophrenia, Parkinson’s disease/syndrome; multiple sclerosis, muscular
dystrophy; amyotrophic lateral sclerosis (ALS); or Huntington’s disease, agent
orange?
Yes
No
Yes
No
Have you been medically diagnosed as having or have you been treated for AIDS
(Acquired Immune Deficiency Syndrome)/AIDS related conditions; or have you
tested positive for antibodies to the AIDS virus?
Yes
No
Yes
No
Do you require supervision or human assistance with: bathing; dressing; eating;
walking; getting in/out of bed or a chair; use of toilet; or bowel/bladder control?
Yes
No
Yes
No
Do you use or have you been advised to use any of the following medical
equipment: wheelchair; motorized scooter; walker; stair lift; quad cane; dialysis; or
oxygen (except for sleep apnea)?
Yes
No
Yes
No
Do you currently reside in, or have been advised to enter or use a nursing home;
an assisted living facility; adult day care; any other type of long-term care facility; or
home health care services?
Yes
No
Yes
No
Do any of your children help you with household chores, your medical care, or help
you with your business affairs?
Yes
No
Yes
No
Have you been diagnosed with COPD (Chronic Obstructive Pulmonary Disease) or
Melanoma Cancer within the last 3 years?
Yes
No
Yes
No
Please return to: Cell: Fax: Email: Common Sense Companies www.commonsensecompanies.com Coonfidential
Peersonal Infformation
Client Nam
me
Spou
use Name
e
Cash
C
Flow
w
ation: Pleas
se enter the type of MON
NTHLY INCO
OME. Exam
mple: Sociall Security, Disability
Financial informa
n or a descriptive catego
ory. Please enter only M
MEDICAL co
osts, no houssehold expe
enses.
Income, Pension
Montthly Incom
me
Client
Spous
se
Inco
ome
Gross
Inco me
Gross
Wag
ges
$
Wag es
$
Social Security
$
Socia
al Security
$
Penssion
$
Penssion
$
Disa
ability
$
Disab
bility
$
IRA Distribution
$
IRA D
Distribution
$
Renttal Income
$
Renttal Income
$
Othe
er __________
___________
_____
$
Otherr __________
___________
_____
$
Total In
ncome $
Total In
ncome $
Monthly
M
Me
edical Care
e Costs
Client
Spous
se
Nurssing Home
$
Nurssing Home
$
Assisted Living
$
Assissted Living
$
Therrapy
$
Therrapy
$
Medicare B
$
Mediicare B
$
Medicare C & D
$
Mediicare C & D
$
Priva
ate Medical Ins/Supplem
mental
$
Priva
ate Medical IIns/Supplem
mental
$
Hom
me Health Aid
d
$
Hom e Health Aid
d
$
Medications
$
Mediications
$
Misccellaneous
$
Misc ellaneous
$
Gran
nd Totals
Pleaase return to
o: Celll: Faxx: Emaiil: Total Costs $
Total Costs $
In
ncome $
Medical C
Costs $
Com
mmon Sen
nse Comp
panies www
w.commonssensecompanies.com Coonfidential
Peersonal Infformation
Client Nam
me
Spou
use Name
e
ASSETS
ase do NOT include acco
ount numberrs, but the ty
ype of accou
unt is importa
ant to fully e
evaluate your eligibility
Plea
for d
different plan
ns. Round account balan
nces to the nearest
n
thou
usand. It is o
okay to lump
p same type
es of
invesstments toge
ether.
We d
do not need to know the
e names of banks
b
or inve
estment com
mpanies.
Client/Joint
Spouse
e
To
otal
Check iif you have the
√ followinng documennts in place
Checcking/Saving
gs/MM
$
$
$
CD’ss
IRA’ss/401K’s
$
$
$
Type
e __________
_______
$
$
$
POA – P
Property/Financial
Type
e __________
_______
$
$
$
Living W
Will
Annu
uities
Cash
h Value of Life
L
Insurance Policie
es
$
$
$
$
$
$
Hom
me
Othe
er Real Estate
$
$
$
Type
e __________
_______
$
$
$
Vehiicles
$
$
$
Othe
er __________
_______
$
$
$
$`
$
POA – H
Health Care
Dated _
____________
_____________
_
Dated _
____________
_____________
_
Invesstment Acco
ounts
Dated _
____________
_____________
_
Total $
Last Willl & Testame
ent
Dated _
____________
_____________
_
Revocab
ble (Living) T
Trust
Dated _
____________
_____________
_
Irrevoca
able Trust
Dated _
____________
_____________
_
Prepaid Funeral Pla
an
Amount $__________
_____
With W
Whom ________
___________
U
Use back of this fhis form fo
or additional
in
nformation
Family
Child
dren's Name Addres
ss/Phone N
Number
Age A
Email, if known Ple
ease enter any
y additional children
c
on a separate
s
piecce of paper orr in your e-ma
ail response.
Pleaase return to
o: Celll: Faxx: Emaiil: Com
mmon Sen
nse Comp
panies www
w.commonssensecompanies.com Confidential
Personal Information
Client Name
Spouse Name
VA AID and ATTENDANCE
Don’t allow a deserving veteran to be denied a tax-free pension!
To determine if you or your spouse could be eligible for VA pension with Aid and Attendance Pension benefits,
you need to know/do the following:
1.
Do you have the original or a certified copy of the military discharge papers (DD214 or equivalent)?
Yes
□
No
□
2. If No, you will need to order the discharge papers from www.vetrecs.archives.gov/ or
call the Veteran Records Center 314-801-0800.
3.
Was the term of service during a War Time Period listed below? Yes
□
No
□
Please provide
Branch of Service: ____________________________________
Service dates:
________________________________________
World War II:
December 7, 1941 thru December 31, 1946
Korean War:
June 27, 1950 thru January 31, 1955
Vietnam Era:
August 5, 1964 thru May 7, 1975 (if serving anywhere)
February 28, 1961 thru May 7, 1975 (if in the country of Vietnam)
Persian Gulf:
August 2, 1980 thru present
4. Does the Veteran or widow need assistance with any of the following activities of daily living?
Check all that apply
□ Driving
□ Toileting
□ Veteran
□ Walking □ Bathing □ Eating
□ Transferring from bed or chair
□ Widow/Spouse or □ Both
□ Dressing
Applies to:
5. What is the total Gross Monthly household income of the veteran, spouse or widow? $____________
6.
Are you currently registered with the Veterans Administration (VA)?
7. Are you currently receiving other Veterans Benefits?
8.
□ Yes □ No
□ Yes □ No
Are you or your spouse currently on Medicaid or have applied for Medicaid?
If yes, ______________________________
□ Yes □ No
9. Do you have a disabled child that resides in your home with you or your spouse?
□ Yes □ No
Please return to: Cell: Fax: Email: Common Sense Companies www.commonsensecompanies.com