5954 N.

College Ave, Indianapolis, IN 46220

Phone (317) 579-9715
Fax (317) 579-8928
Email selder@elder-legal.com
Website elder-legal.com

Information Sheet Life Care Planning for a Couple

Please complete this form prior to your initial meeting to allow us to more efficiently serve
your needs. This form is intended to be completed by married couples. If you are
completing this sheet on behalf of the couple, please put your information in Section B
Contact Person. Please use the back of the form if additional space is needed. If a section
does not apply to you, please ignore it.

A. PERSONAL INFORMATION

Partner 1 Partner 2
Full Legal Name _________________________ ________________________

Date of Birth/age _________________________ _________________________

Social Security No. ________________________ _________________________

Home Phone _________________________ _________________________

Cell Phone _________________________ _________________________

Other Phone _________________________ _________________________

Email _________________________ _________________________

Last Grade Completed ____________________ _________________________

Home Street Address ____________________ _________________________

Home City, State, Zip ____________________ _________________________

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County of Residence ____________________ _________________________

How do you prefer we contact you? (Please circle all that apply)

Partner 1 Cell phone Home Phone E-mail Other_____________

Partner 2 Cell phone Home Phone E-mail Other_____________

Date of Marriage______________________

Have you been convicted of a felony? Partner 1 Yes No Partner 2 Yes No

Are you a U. S. Citizen? Partner 1 Yes No Partner 2 Yes No

Have you served in the military on active duty during a war time period?

Partner 1 Yes No Partner 2 Yes No

Were you injured during your active duty? Yes No

Are you receiving VA benefits? Partner 1 Yes No Partner 2 Yes No

If yes, what type? Pension Partner 1 Partner 2

Health Care Partner 1 Partner 2 Compensation Partner 1 Partner 2

Have you or anyone in your family filed for Medicaid, Food Stamps, or TANF
benefits before? Yes No If yes, who filed and for which program?
________________________________________________________________________
________________________________________________________________________
Do you have a Power of Attorney?

Partner 1 Yes No

POA Name(s)___________________________________________________________

Relationship to you ______________________________________________________

Powers Granted: Health Care Business/Financial/Estate

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Office Use- Copy in file? Yes No

Partner 2 Yes No

POA Name(s)___________________________________________________________

Relationship to you ______________________________________________________

Powers Granted: Health Care Business/Financial/Estate

Office Use- Copy in file? Yes No

Do you now or have you ever had a guardian?

Partner 1 Yes Circle the type of guardianship: Estate Person Both

Guardians Name(s)______________________________________________________

Relationship to you ______________________________________________________

Partner 2 Yes Circle the type of guardianship: Estate Person Both

Guardians Name(s)______________________________________________________

Relationship to you ______________________________________________________

Are you currently or have you ever been hospitalized for 30 consecutive days?

Partner 1 Yes No Partner 2 Yes No

If yes: Hospital name and location Date admitted Release Date

Partner 1 _______________________ ____________ ____________

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 Partner 2 _______________________ ____________ ____________

1. Describe your current health including any current diagnoses, date of diagnosis,
and conditions for which you take medication:
Partner 1_______________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Partner 2_______________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

B. CONTACT PERSON (person completing this form if not Partner 1 or Partner 2)

Full Legal Name_______________________________________________________

Street _______________________________________SSN__________________

City, State, Zip ________________________________________________________

Phone(s) Home______________ Work_____________ Cell______________

Other______________

Relationship to clients___________________ Email_________________________

How do you prefer we contact you? (Please circle all that apply)

Cell Phone Home Phone Email Other______________

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C. LIVING ARRANGEMENTS

Has anyone lived with you during the past 2 years or have you lived with anyone
during the past 2 years?
Partner 1 Yes No Partner 2 Yes No

If yes, please explain the circumstances:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Do you currently live in your home?

Partner 1
_______ Yes and I do not currently foresee moving out of my home
_______ Yes, but I anticipate moving to an assisted living or nursing home facility
within the next: ________ days ________ months
_______ No, but I anticipate moving back home on_____________________
_______ No and I do not anticipate moving back home

Partner 2
_______ Yes and I do not currently foresee moving out of my home
_______ Yes, but I anticipate moving to an assisted living or nursing home facility
within the next: ________ days ________ months
_______ No, but I anticipate moving back home on_____________________
_______ No and I do not anticipate moving back home

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 Provide the following information if you are not living at home or if you anticipate
moving from your home:

1. Partner 1 Partner 2 Both (please circle)

Facility Name or Relatives Name with whom you live

________________________________________________________________________
Street _______________________________________________________________
City, State, Zip __________________________________________________________

County________________ Phone__________________________

If you are currently or have been in a facility:

Date admitted________________ Date of discharge_______________

2. Partner 1 Partner 2 Both (please circle)

Facility Name or Relatives Name with whom you live

________________________________________________________________________
Street __________________________________________________________________
City, State, Zip ___________________________________________________________

County________________ Phone__________________________

If you are currently or have been in a facility:

Date admitted________________ Date of discharge_______________

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D. CHILDREN (please list all of your children and indicate if a child from a previous
relationship)

1. Full Legal Name__________________________________________________________

Address_________________________________________________________________

Phone _________________________ Email_______________________________

2. Full Legal Name__________________________________________________________

Address_________________________________________________________________

Phone _________________________ Email_______________________________

3. Full Legal Name__________________________________________________________

Address_________________________________________________________________

Phone _________________________ Email_______________________________

4. Full Legal Name__________________________________________________________

Address_________________________________________________________________

Phone _________________________ Email_______________________________

5. Full Legal Name__________________________________________________________

Address_________________________________________________________________

Phone _________________________ Email_______________________________

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6. Full Legal Name__________________________________________________________

Address_________________________________________________________________

Phone _________________________ Email_______________________________

May I communicate with your children? Yes No

Do any of your children receive Social Security benefits? Yes No

E. OTHER IMPORTANT PEOPLE

Please provide the following information for anyone else that will be involved with your
Life Care Planning or may attend meetings with us:
Name___________________________________________________________________

Address_________________________________________________________________

Phone(s) Home______________ Work_____________ Cell________________

Relationship to you___________________ Email______________________________

May I communicate with this person? Yes No

Name___________________________________________________________________

Address_________________________________________________________________

Phone(s) Home______________ Work_____________ Cell________________

Relationship to you___________________ Email___________________________

May I communicate with this person? Yes No

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F. MONTHLY INCOME
Partner 1 Partner 2

Salary ___________________ ____________________

Social Security ___________________ ____________________

Pension ___________________ ____________________

Annuity ___________________ ____________________

VA Benefit ___________________ ____________________

Have you ever received Social Security and then stopped receipt?
P1 Yes No P2 Yes No

G. EXPENSES

Supplemental Health Insurance (Please list separately for P1 and P2):

Partner 1s Monthly premium:_________ Company Name: _____________________

Partner 2s Monthly premium:_________ Company Name: _____________________

Long Term Care Insurance

Partner 1s Monthly premium:_________ Company Name: _____________________

Partner 2s Monthly premium:_________ Company Name: _____________________

*** Please Provide Copies of all Insurance Policies ***

Monthly Utilities: _________________________________________________________

Monthly House payment or rent payment: _____________________________________

Annual Real Estate Taxes: __________________________________________________

Annual Property Insurance: _________________________________________________

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 H. ASSETS

Safety Deposit Box? Yes No If yes, location_____________________________

Do you own a qualified annuity (funded with retirement funds)? Yes No

Do you own a non-qualified annuity (funded with retirement funds)? Yes No

Do you own cemetery lots? Yes No

If yes, please provide a copy of the deed for such lot(s).

Do you own prepaid funeral arrangements?

P1 Yes No P2 Yes No
**If yes, please provide us with all documents pertaining to such arrangements.**

Bank Accounts
Institution Type of Account Current Value Owner

1. _______________________ _________________________ $________ _______

2. _______________________ _________________________ $________ _______

3. _______________________ _________________________ $________ _______

Total

Stocks, Bonds, Treasury Notes, Other Investments

Description Number Current Value Owner

1. __________________ ________________ $___________________ _______

2. __________________ ________________ $___________________ _______

3. __________________ ________________ $___________________ _______

4. __________________ ________________ $___________________ _______

Total
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Life Insurance

1. Company _____________________________ Policy Number_______________________

Face Value ____________________________ Cash Surrender Value _________________

Owner_____________________________ Beneficiary__________________________

2. Company _____________________________ Policy Number_______________________

Face Value ____________________________ Cash Surrender Value _________________

Owner_____________________________ Beneficiary__________________________

3. Company _____________________________ Policy Number_______________________

Face Value ____________________________ Cash Surrender Value _________________

Owner_____________________________ Beneficiary__________________________

4. Company _____________________________ Policy Number_______________________

Face Value ____________________________ Cash Surrender Value _________________

Owner_____________________________ Beneficiary__________________________

Real Estate
*please provide a copy of the most current deed(s) and real estate tax bill(s)*

Address Current Name(s) on deed

Value
1. ______________________________ $________ ____________________________

2. ______________________________ $________ ____________________________

Total

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Vehicles
Make, Model, Current Mileage Current Value Owner

1. _______________________________________________ $________ _______

2. _______________________ _______________________ $________ _______

3. _______________________ _______________________ $________ _______

IRAs, Pension, 401K, Annuities, Mutual Funds

Company Account No. Current Value

1. _______________________ ____________________ $________ ___

Owner____________________ Beneficiary_______________________

2. _______________________ ____________________ $________ ___

Owner____________________ Beneficiary_______________________

3. _______________________ ____________________ $________ ___

Owner____________________ Beneficiary_______________________

4. _______________________ ____________________ $________ ___

Owner____________________ Beneficiary_______________________

5. _______________________ ____________________ $________ ___

Owner____________________ Beneficiary_______________________

Total

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Business Interests or Other Miscellaneous Assets

(Please list any additional assets not included above including

any interest you have in a business)

Description Current Value Owner

1. _________________________________________ $___________ _____________

2. ___________________________________________ $___________ _____________

3. ___________________________________________ $___________ _____________

Asset Recapitulation
Current Value
Bank Accounts $_________
Stocks, Bonds, Treasury Notes, Other Investments $_________
Life Insurance $_________
Real Estate $_________
IRAs, Pension, 401K, Annuities, Mutual Funds $_________
Miscellaneous $_________
Total
I. LOANS

Does anyone presently owe you any money (or other debt)? Yes No

If yes, do you have written documentation signed by the debtor? Yes No

Please list the amount owed to you for each loan and payment terms:____________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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 J. GIFTS

For gifts made on or after November 1, 2009, please list all gifts made (no matter how
small or for what reason- including gifts to charities and churches). Please use a separate
sheet of paper if necessary.

Date Amount Recipient

_________________
_________________
_________________
_________________
_________________
______________________
______________________
______________________
______________________
______________________
____________________
____________________
____________________
____________________
____________________

K. LIABILITIES
Personal or Bank Loans, Credit Card Debt, Mortgages, etc.
Person or Company Description of loan Amount Owed Debtor

1. ___________________________ _________________ $___________ __________

2. ___________________________ _________________ $___________ __________

3. ___________________________ _________________ $___________ __________

4. ___________________________ _________________ $___________ __________

Total

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Has anyone assisted you in paying for your living expenses or healthcare? Yes No

If yes, please explain: ______________________________________________________

Has anyone assisted you with everyday activities such as medications, cooking,

housekeeping, grocery shopping, etc.? Yes No

If yes, please explain: ______________________________________________________

Has anyone provided transportation for you to and from medical appointments or

treatments? Yes No

If yes, please explain: ______________________________________________________

Did this person(s) take off work so that they could transport you? Yes No

What are your biggest concerns?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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What questions would you like address during our meeting?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Is there anything else that you believe is important for me to know?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Referral:
Who referred you to this office?

Name___________________________________________________________________

___________________________________ Date:______________________________
Partner 1s Signature

___________________________________ Date:______________________________
Partner 2s Signature

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