Medicaid Planning Survey Form

Note: If applicant is married, information is required for applicant AND spouse

SECTION 1: GENERAL INFORMATION
APPLICANT
Full Name  
Home Address or Nursing Home Address  
If in nursing home, date of admission  
Date of birth  
Social Security No  
Email Address  
SPOUSE
Name  
Date of Marriage  
Date of Birth  
Soc. Sec. #  
If deceased, date of death  
Spouse Address  
Home Phone  
Cell Phone  
Work Phone  
Emai Addressl  
CHIILDREN (if applicable)
Child 1  
Street Address  
City  
State  
Zip  
Home Phone with area code  
Work Phone with area code  
Cell Phone with area code  
Date of Birth  
Email Address  
Child 2  
Street Address  
City  
State  
Zip  
Home Phone with area code  
Work Phone with area code  
Cell Phone with area code  
Date of Birth  
Email Address  
Child 3  
Street Address  
City  
State  
Zip  
Home Phone with area code  
Work Phone with area code  
Cell Phone with area code  
Date of Birth  
Email Address  
Child 4  
Street Address  
City  
State  
Zip  
Home Phone with area code  
Work Phone with area code  
Cell Phone with area code  
Date of Birth  
Email Address  
Child 5  
Street Address  
City  
State  
Zip  
Home Phone with area code  
Work Phone with area code  
Cell Phone with area code  
Date of Birth  
Email Address  
Child 6  
Street Address  
City  
State  
Zip  
Home Phone with area code  
Work Phone with area code  
Cell Phone with area code  
Date of Birth  
Email Address  

SECTION 2: ASSETS & FORM OF OWNERSHIP
Real Estate
Home
Does applicant own his/her own home?   Yes No
If yes, type of ownership  
Street address  
City  
State  
Zip  
Other Real Property Owned
If yes, type of ownership  
Street address  
City  
State  
Zip  
Approximate value  
IRAs, Pensions, 401Ks, Retirement Plans
Bank or Brokerage  
Account Number  
Type of Ownership  
Approximate value  
Bank or Brokerage  
Account Number  
Type of Ownership  
Approximate value  
Bank or Brokerage  
Account Number  
Type of Ownership  
Approximate value  
Bank or Brokerage  
Account Number  
Type of Ownership  
Approximate value  
Bank Accounts (all accounts held past 36 months. Exclude IRA and retirement type accounts)
Bank  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Bank  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Bank  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Bank  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Bank  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Bank  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Bank  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Company & Policy #  
Approx. Value  
Owner  
Annuitant's Name  
Company & Policy #  
Approx. Value  
Owner  
Annuitant's Name  
Company & Policy #  
Approx. Value  
Owner  
Annuitant's Name  
Company & Policy #  
Approx. Value  
Owner  
Annuitant's Name  
Brokerage Accounts (those held past 36 months WITH a broker. Exclude IRA/Retirement Type)
Broker  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Broker  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Broker  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Broker  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Broker  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Broker  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Individually Held Stocks, Bonds, Mutual Funds (Exclude IRA/Retirement type)
Stock/Bond/Mut Fund  
Type of Ownership  
Approx. Value  
If closed, date closed  
Stock/Bond/Mut Fund  
Account #  
Account Type  
Type of Ownership  
Approx. Value  
If closed, date closed  
Stock/Bond/Mut Fund  
Type of Ownership  
Approx. Value  
If closed, date closed  
Stock/Bond/Mut Fund  
Type of Ownership  
Approx. Value  
If closed, date closed  
Stock/Bond/Mut Fund  
Type of Ownership  
Approx. Value  
If closed, date closed  
Stock/Bond/Mut Fund  
Type of Ownership  
Approx. Value  
If closed, date closed  
Any other assets not listed above. Please provide type, ownership, value:
 

SECTION 3: TRANSFERS
Have you given away or sold real property or other assets within the past 3 years?   Yes No
If yes
Property  
Value in $  
Type of Transfer  
Date of Transfer  
Property  
Value in $  
Type of Transfer  
Date of Transfer  
Property  
Value in $  
Type of Transfer  
Date of Transfer  
Property  
Value in $  
Type of Transfer  
Date of Transfer  

SECTION 4: INCOME
Applicant
Social Security Per Month  
Pension Per Month  
Veteran Benefits Per Month  
Other Income Per Month  
Spouse (if applicable)
Social Security Per Month  
Pension Per Month  
Veteran Benefits Per Month  
Other Income Per Month  

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)?

   Yes No
Has prepaid funeral?   Yes No
If yes, funeral director  
Has burial plot?   Yes No
Owns automobile?   Yes No
Has safe deposit box?   Yes No
Has healthcare proxy?   Yes No
Has living will?   Yes No
Has trust?   Yes No
Have power of attorney? Yes No
If yes, held by whom  
Have Medicare?   Yes No
If yes
Part A?   Yes No
Part B?   Yes No
Medicare ID#
Has private health insurance?   Yes No
If yes, company
ID#  
Monthly Premium  
Veteran?   Yes No
Is expecting an inheritance?   Yes No
Spouse
Veteran?   Yes No
Is expecting an inheritance?   Yes No
Name, Address and Phone Number (s) of Person completing this form, if other than client:  

SECTION 6: YOUR COMMENTS & QUESTIONS

Please use this area for any additional information, or comments or questions:
 
Please tell us how you learned about The Karp Law Firm: