Medicaid Estate Planning Questionnaire

Medicaid Estate Planning Questionnaire

  • Applicant Information

  • Prior Gifts/Transfers (1)

    Have you made any gifts in the past three years?
  • Prior Gifts/Transfers (2)

    Have you made any gifts in the past three years?
  • Prior Gifts/Transfers (3)

    Have you made any gifts in the past three years?
  • Prior Gifts/Transfers (4)

    Have you made any gifts in the past three years?
  • Children (1)

  • Children (2)

  • Children (3)

  • Children (4)

  • Children (5)

  • Children (6)

  • Children (7)

  • Grandchildren (1)

  • Grandchildren (2)

  • Grandchildren (3)

  • Grandchildren (4)

  • Grandchildren (5)

  • Grandchildren (6)

  • Grandchildren (7)

  • Current Estate Planning Documents

    Please indicate the current estate planning documentation that you have in place. Please select N/A for any item that is not applicable.
  • Estate Assets

    Assets include the home, rental or real estate investment property, vehicles, IRA (Individual Retirement Accounts), Pension of 401k plan, cash, brokerage accounts, stocks, bonds, CDs, LIfe Insurance (both face and cash values).
  • AssetTitle (Ownership)Value 
    Add a new row
  • Income

  • Social SecurityGrossNet 
  • PensionGrossNet 
  • Veteran PaymentsGrossNet 
  • IRA DistributionGrossNet 
  • Rental IncomeGrossNet 
  • InterestGrossNet 
  • DividendsGrossNet 
  • WagesGrossNet 
  • AlimonyGrossNet 
  • Annuity PaymentsGrossNet 
  • OtherGrossNet 
  • TotalGrossNet 
  • Personal Representative (1)

    Who would you want to handle your final affairs?
  • Personal Representative (2)

    Who would you want to handle your final affairs?
  • Personal Representative (3)

    Who would you want to handle your final affairs?
  • Trustee/Attorney-In-Fact (1)

    Who would you want to handle your financial affairs if you are unable to?
  • Trustee/Attorney-In-Fact (2)

    Who would you want to handle your financial affairs if you are unable to?
  • Trustee/Attorney-In-Fact (3)

    Who would you want to handle your financial affairs if you are unable to?
  • Documentation

    Please provide the following documentation if you wish to immediately apply for Medicaid.
  • Important Contacts

  • Acknowledgment

    I understand that is is my responsibility to disclose correct and complete information. I hereby attest that the information I have supplied is complete and accurate to the best of my knowledge. I realize that any changes must be reported as soon as possible.