Crisis Medicaid Planning Questionnaire – Married Step 1 of 4 25% Attorney or Advisor’s Contact InformationAttorney or Advisor’s Name First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFacsimile:Email A. PERSONAL DATAName (Husband)* First Last Name (Wife)* First Last Address Street Address City ZIP Code State*Birth Date (Husband)* Date Format: DD slash MM slash YYYY Birth Date (Wife)* Date Format: DD slash MM slash YYYY U. S. Citizen? (Husband)YesNoU. S. Citizen? (Wife)YesNoVeteran? (Husband)YesNoVeteran? (Wife)YesNo B. MEDICAL DATAName of Ill Spouse First Last DiagnosisCourse of TreatmentWhere ill Spouse Currently Resides Street Address City Name of Well Spouse First Last Health of Well SpouseWhere Well Spouse Currently Resides Street Address City If either spouse has already entered a nursing home, please indicate the name of the nursing home and the first date entered on a continuous basis C. MONTHLY INCOME $Do not include interest and dividend income on this form. If there is a pension, please list the gross pension amount, including any monies taken out for federal income taxes, health insurance, or any other reasonHusband’s Monthly IncomeSocial Security BenefitRetirement Benefit (Gross)VA Disability BenefitAnnuity IncomeRental IncomeTotal Monthly IncomeWife’s Monthly IncomeSocial Security BenefitRetirement Benefit (Gross)VA Disability BenefitAnnuity IncomeRental IncomeTotal Monthly IncomeD. MONTHLY COST OF NURSING HOMEMonthly Cost in $Monthly Nursing Home CostMonthly Incidental CostMonthly Prescription CostMonthly Other CostTotal Monthly CostsThe nursing home is paid through DD MM YYYY As such, if applicable, please provide the Medicaid per diem rate:If the nursing home facility is located in New Hampshire, Kansas, Ohio, or PennsylvaniaAFFC will require the nursing home facility’s Medicaid per diem rate to develop the appropriate Medicaid Compliant Annuity Plan.E. ASSETS/LIABILITIES(Please insert the value of each asset/liability in the appropriate space.)List of Assets: (use + button to add more rows)AssetValueLiability Include these asset above if available: AUTOMOBILE, CHECKING ACCOUNT, SAVINGS ACCOUNT, MONEY MARKET ACCOUNT, CERTIFICATES OF DEPOSIT, RESIDENCE, MUTUAL FUNDS, STOCKS, BONDS, ANNUITIES, IRA, OTHER REAL ESTATE, NURSING HOME DEPOSIT and Others. F. LIFE INSURANCE(Please insert the value of each life insurance in the appropriate space.) (Include address and policy No. in Company Name)List of Life Insurance: (use + button to add more rows)COMPANY NAMETYPEDEATH BENEFIT VALUEFACE VALUECASH VALUEINSUREDINSUREDBENEFICIARY It is very important to know the cash value and the death benefit of your life insurance policy. To obtain the cash value of the policy, please call your insurance agent, or call the insurance company directly.G. GIFTSPlease list gifts made in excess of $100.00 in any one month, to an individual or group of individuals, within the past 60 months:List of GiftsRecipientDateAmount (use + button to add more rows)Have you ever filed a Federal Gift Tax Return?YesNoIf so, please state detailsCAPTCHACommentsThis field is for validation purposes and should be left unchanged. REQUEST A FREE QUOTE! Get a Free Comprehensive Quote for Your Client Today! Free Client Quote REQUEST A FREE QUOTE! GET A FREE COMPREHENSIVE QUOTEFOR YOUR CLIENT TODAY! Free Client Quote HQ WealthMerge 906 McClain Rd., #3002Bentonville, AR 72712