Note: If applicant is married, information is required for applicant AND spouse |
SECTION 1: GENERAL INFORMATION |
APPLICANT |
Full Name |
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Home Address or Nursing Home Address |
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If in nursing home, date of admission |
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Date of birth |
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Social Security No |
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Email Address |
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SPOUSE |
Name |
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Date of Marriage |
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Date of Birth |
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Soc. Sec. # |
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If deceased, date of death |
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Spouse Address |
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Home Phone |
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Cell Phone |
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Work Phone |
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Emai Addressl |
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CHIILDREN (if applicable) |
Child 1 |
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Street Address |
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City |
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State |
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Zip |
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Home Phone with area code |
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Work Phone with area code |
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Cell Phone with area code |
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Date of Birth |
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Email Address |
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Child 2 |
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Street Address |
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City |
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State |
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Zip |
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Home Phone with area code |
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Work Phone with area code |
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Cell Phone with area code |
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Date of Birth |
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Email Address |
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Child 3 |
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Street Address |
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City |
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State |
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Zip |
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Home Phone with area code |
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Work Phone with area code |
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Cell Phone with area code |
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Date of Birth |
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Email Address |
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Child 4 |
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Street Address |
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City |
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State |
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Zip |
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Home Phone with area code |
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Work Phone with area code |
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Cell Phone with area code |
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Date of Birth |
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Email Address |
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Child 5 |
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Street Address |
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City |
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State |
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Zip |
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Home Phone with area code |
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Work Phone with area code |
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Cell Phone with area code |
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Date of Birth |
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Email Address |
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Child 6 |
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Street Address |
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City |
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State |
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Zip |
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Home Phone with area code |
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Work Phone with area code |
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Cell Phone with area code |
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Date of Birth |
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Email Address |
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SECTION 2: ASSETS & FORM OF OWNERSHIP |
Real Estate |
Home |
Does applicant own his/her own home? |
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Yes
No
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If yes, type of ownership |
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Street address |
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City |
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State |
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Zip |
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Other Real Property Owned |
If yes, type of ownership |
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Street address |
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City |
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State |
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Zip |
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Approximate value |
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IRAs, Pensions, 401Ks, Retirement Plans |
Bank or Brokerage |
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Account Number |
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Type of Ownership |
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Approximate value |
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Bank or Brokerage |
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Account Number |
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Type of Ownership |
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Approximate value |
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Bank or Brokerage |
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Account Number |
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Type of Ownership |
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Approximate value |
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Bank or Brokerage |
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Account Number |
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Type of Ownership |
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Approximate value |
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Bank Accounts (all accounts held past 36 months. Exclude IRA and retirement type accounts) |
Bank |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Bank |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Bank |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Bank |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Bank |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Bank |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Bank |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Company & Policy # |
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Approx. Value |
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Owner |
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Annuitant's Name |
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Company & Policy # |
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Approx. Value |
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Owner |
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Annuitant's Name |
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Company & Policy # |
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Approx. Value |
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Owner |
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Annuitant's Name |
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Company & Policy # |
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Approx. Value |
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Owner |
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Annuitant's Name |
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Brokerage Accounts (those held past 36 months WITH a broker. Exclude IRA/Retirement Type) |
Broker |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Broker |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Broker |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Broker |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Broker |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Broker |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Individually Held Stocks, Bonds, Mutual Funds (Exclude IRA/Retirement type) |
Stock/Bond/Mut Fund |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Stock/Bond/Mut Fund |
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Account # |
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Account Type |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Stock/Bond/Mut Fund |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Stock/Bond/Mut Fund |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Stock/Bond/Mut Fund |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Stock/Bond/Mut Fund |
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Type of Ownership |
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Approx. Value |
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If closed, date closed |
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Any other assets not listed above. Please provide type, ownership, value: |
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SECTION 3: TRANSFERS |
Have you given away or sold real property or other assets within the past 3 years? |
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Yes
No
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If yes |
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Property |
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Value in $ |
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Type of Transfer |
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Date of Transfer |
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Property |
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Value in $ |
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Type of Transfer |
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Date of Transfer |
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Property |
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Value in $ |
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Type of Transfer |
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Date of Transfer |
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Property |
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Value in $ |
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Type of Transfer |
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Date of Transfer |
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SECTION 4: INCOME |
Applicant |
Social Security Per Month |
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Pension Per Month |
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Veteran Benefits Per Month |
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Other Income Per Month |
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Spouse (if applicable) |
Social Security Per Month |
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Pension Per Month |
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Veteran Benefits Per Month |
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Other Income Per Month |
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SECTION 5: ADDITIONAL QUESTIONS |
Regarding the applicant: |
Does the APPLICANT have a CHILD who
is disabled or receiving Social Security
Disability Insurance (SSDI) or Supplemental Security Income (SSI)? |
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Yes
No
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Has prepaid funeral? |
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Yes
No
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If yes, funeral director |
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Has burial plot? |
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Yes
No
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Owns automobile? |
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Yes
No
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Has safe deposit box? |
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Yes
No
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Has healthcare proxy? |
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Yes
No
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Has living will? |
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Yes
No
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Has trust? |
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Yes
No
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Have power of attorney? |
Yes
No
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If yes, held by whom |
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Have Medicare? |
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Yes
No
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If yes |
Part A? |
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Yes
No
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Part B? |
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Yes
No
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Medicare ID# |
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Has private health insurance? |
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Yes
No
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If yes, company |
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ID# |
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Monthly Premium |
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Veteran? |
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Yes
No
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Is expecting an inheritance? |
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Yes
No
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Spouse |
Veteran? |
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Yes
No
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Is expecting an inheritance? |
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Yes
No
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Name, Address and Phone Number (s) of Person completing this form, if other than client: |
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SECTION 6: YOUR COMMENTS & QUESTIONSPlease use this area for any additional information, or comments or questions: |
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Please tell us how you learned about The Karp Law Firm: |
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