MEDICAID ESTATE PLANNING QUESTIONNAIRE

Please fill out the form below.

Name & Contact Information

Person Completing Form:

First Name

Middle Name

Last Name

Relationship to Client

Home Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Client's Information:

First Name

Middle Name

Last Name

Home Phone #

Cell Phone #

Date of Birth

Former/Maiden Names

US Citizen?

Yes No

Social Security #

Military Service

Date of Death

Spouse's Information:

First Name

Middle Name

Last Name

Client's/Spouse's Address:

Home Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Home Phone #

Cell Phone #

Date of Birth

Former/Maiden Names

US Citizen?

Yes No

Social Security #

Military Service

Date of Death

Marital Information

Date of Marriage

Place of Marriage - City

State or Province

Country

Client's Former Spouses:

VISIT.

402 S. Kentucky Ave.
Suite 600
Lakeland, FL 33801

PAY.

CONNECT.

(863) 682-9730
info@medinapa.com

Certified Financial Planner Board of Standards, Inc. (CFP Board) owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™, and CFP® (with plaque design)
in the United States, which it authorizes use of by individuals who successfully complete CFP Board’s initial and ongoing certification requirements.

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