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Home
Who We Are
Services
Estate Planning
Living Trusts
Wills
Power Of Attorney
Medi-Cal Planning
Medi-Cal Planning Overview
Medi-Cal Planning for Married Couples
In-Home Support Services
Medi-Cal Recovery
Special Needs Planning
Special Needs Trusts
Conservatorships
Probate
Probate
Trust Administration
First Steps After Death
Resources
Testimonials
Blog
Contact
LONG-TERM CARE PLANNING WORKSHEET
Step
1
of
7
14%
MEDI-CAL APPLICANT INFORMATION
Marital Status
Single
Married
Divorced
Separated
Widowed
Name
First
Middle
Last
Nickname (if any)
Alias Name (if any)
Gender
Female
Male
Date of Birth
MM slash DD slash YYYY
U.S. Citizen
Yes
No
If No, please specify citizenship
Veteran
Yes
No
Is the Medi-Cal Applicant currently in a nursing home? If yes, please type the name of the facility
SPOUSE OF MEDI-CAL APPLICANT INFORMATION (IF APPLICABLE)
Name
First
Middle
Last
Nickname (if any)
Alias Name (if any)
Name
Gender
Female
Male
Date of Birth
MM slash DD slash YYYY
U.S. Citizen
Yes
No
If No, specify citizenship
Veteran
Yes
No
Phone
Email
If you are the main point of contact that our office should communicate with, please check the box below and skip the next section.
Yes
WHO SHOULD OUR OFFICE KEEP IN CONTACT WITH REGARDING THE MEDI-CAL APPLICANT'S CASE?
Name
First
Last
What is your relationship with Medi-Cal Applicant?
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Contact Email
INCOME
Medi-Cal Applicant’s Monthly Income (SSI, PENSION, ANNUITY, IRA, ETC.)
Does the Medi-Cal Applicant Have An IRA?
Not Sure
Yes
No
Does Medi-Cal Applicant have any pension plans?
Not Sure
Yes
No
Spouse Monthly Income (SSI, PENSION, ANNUITY, IRA, ETC.)
Does the Spouse have an IRA?
Not Applicable
Yes
No
Does Spouse have any pension plans?
Not Applicable
Yes
No
REAL PROPERTY
Real Property
Type of Property (Personal Residence, Rental, Vacation, Timeshare, Land)
Address
Add
Remove
BANK ACCOUNTS
Bank Accounts
Type of Account (Checking, Savings, Money Market)
Account Owner
Name of Bank
Current Amount
Add
Remove
BROKERAGE ACCOUNTS
Brokerage Accounts
Company Name
Account Owner
Current Amount
Add
Remove
IRA'S
IRA’s
Company Name
Owner
Beneficiary
Value
Add
Remove
ANNUITIES
Annuities
Company Name
Account Owner
Current Monthly Pay Out
Add
Remove
LIFE INSURANCE
Life Insurance
Company Name
Type (Whole, Universal, or Term)
Owner
Beneficiary
Cash Value
Death Benefit
Add
Remove
PRE-PAID BURIAL
Pre-Paid Burial
Company Name
Owner
Add
Remove
TRANSACTION HISTORY
Within the past 30 months, did the Medi-Cal Applicant, and if applicable, the Spouse of the applicant, transfer, sell, trade, or give away any of the following assets?
Property
Over $10,000
Vehicle(s)
IF YES, please explain.
DO YOU HAVE ANY QUESTIONS OR CONCERNS?
