YOUR FAMILY - Cipparone & Zaccaro



Cipparone & Zaccaro, PCClient Information FormPERSONAL DATADate: ___________Your Name:__________________________________Citizenship:_______________________Other names, including birth name, if applicable: ____________________________________________DOB: ___________SSN: ________________ Place of Birth (City & State): _____________________Address:_____________________________________Day Phone: _________________________________________________ Evening Phone:_____________E-mail Address: ____________________Previous Address if lived at address for less than 36 months______________________________________________________________________Address:Nursing Home/Assisted Living/Rehab______________________________________________________________________Mailing Address: ________________________________________________________Retirement Date: __________________Employer: _____________________________Veteran: Yes ___ No ____Active Duty: Yes ____ No _____Honorable Discharge: Yes _____ No _____Branch of Service:_________________Military Service No. ________________Claim No. _______________________During Wartime? Yes ___ No ____ Dates of Service: _______________________Do you receive any Veterans Benefits? Yes ____ No ____If so, what kind, how much and for how long: __________________________________Your Spouse’s Name ____________________________Citizenship: __________________Other names, including birth name, if applicable: ____________________________________DOB: ___________SSN: ________________ DOD if deceased: ____________Place of Birth (City & State): _________________________Address if not the same as yours:_______________________________________________E-mail Address: ____________________ Day Phone: ___________Evening Phone:______________Mailing Address if not the same as yours: ___________________________________________Retirement Date: __________________ Employer: __________________________________Veteran: Yes ___ No ____Active Duty: Yes ____ No _____Honorable Discharge: Yes _____ No _____Branch of Service:_________________Military Service No. ________________Claim No. _______________________During Wartime? Yes ___ No ____ Dates of Service: _______________________Do you receive any Veterans Benefits? Yes ____ No ____If so, what kind, how much and for how long: __________________________________Date of Marriage: _________Date of Divorce: _____________YOUR FAMILYChildren (Name, Address, Phone, E-mail)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you or your spouse have children from a previous marriage? If so, which children listed above are yours and which are your spouse’s children:__________________________________________________________________________________________________________________________________________Have any of your children died leaving children? Yes ___ No ____ If so, who are their children? (Name, Address, Phone, E-mail)_________________________________________________________________________________________________________________________________________________________________________________________________________Are any of your children disabled? Yes ___ No _____ If yes, please explain:______________________________________________________________________What kind of proof of disability do you have? Doctor’s letter ___ SSI letter ___ SSDI ____What is the child’s SSI or SSDI Number? _______________________________MEDICAL CONDITIONAre you or your spouse currently ill or disabled or at risk for becoming seriously ill or disabled? Yes ___ No ____ If yes, please explain: _______________________________________________________________________________________________________________________Your Doctor:________________________________Phone: ______________________Address: ______________________________________Fax: ________________________Your Spouse’s Doctor ___________________________Phone: ______________________Address: _______________________________________Fax: ________________________Have you or spouse recently entered a hospital or nursing home? Yes ____ No _______You _____ Spouse______Facility Name: _________________________________Phone: ________________Date of Admission _____________Fax: ____________Address: ______________________________________________________________Date of Discharge: __________Diagnosis: _______________________________If still in facility, cost of care per day:____________________Facility Name: _________________________________Phone: ________________Date of Admission _____________Fax: ____________Address: ______________________________________________________________Date of Discharge: __________Diagnosis: _______________________________If still in facility, cost of care per day:____________________MEDICAL INSURANCEMedicare Nos.: ___________________________________________YoursYour Spouse’sHealth InsuranceEmployer: _______________________________________________YoursYour Spouse’sPolicy No.: _______________________________________________YoursYour Spouse’sGroup No.: ______________________________________________YoursYour Spouse’sEffective Date: ___________________________________________YoursYour Spouse’sMedicare SupplementEmployer: ___________________________________________YoursYour Spouse’sPolicy No.: ___________________________________________YoursYour Spouse’sGroup No.: ___________________________________________YoursYour Spouse’sEffective Date: ________________________________________YoursYour Spouse’sLong-Term Care InsuranceEmployer: ___________________________________________YoursYour Spouse’sPolicy No.: ___________________________________________YoursYour Spouse’sGroup No.: ___________________________________________YoursYour Spouse’sEffective Date: ___________________________________________YoursYour Spouse’sLifetime Cap: ___________________________________________YoursYour Spouse’sDaily Rate: ___________________________________________YoursYour Spouse’sMedicaidTitle 19 No.: _____________________________________________YoursYour Spouse’sEffective Date: ___________________________________________YoursYour Spouse’sHave you or your spouse made any gifts of $1,000 or more during the past 5 years?Date of Gift __________Amount _________To Whom ________________________Date of Gift __________Amount _________To Whom ________________________Date of Gift __________Amount _________To Whom ________________________If the gift was real property, please submit a market analysis of the property on the approximate date of this transfer.ASSETSOpen Accounts(Bank accounts, CDs, Brokerage Accounts, IRAs, Annuities, etc.)Type of Account*Name(s) on AccountFinancial InstitutionAccount NumberCurrent ValueBeneficiaryType of Account*Name(s) on AccountFinancial InstitutionAccount NumberCurrent ValueBeneficiaryRetirement, checking, savings, CD, annuity, etc.Closed Accounts(past 3 years)Type of AccountName(s) on AccountFinancial InstitutionAccount NumberCurrent ValueBeneficiaryReal EstateAddressName(s) on TitlePurchase DatePurchase PriceCurrent ValueMortgage (Bank, balance due)Personal Property (Cars, RVs, Boats, Antiques, Jewelry, Collectibles, etc.)Description of AssetOwner(s)Purchase PriceCurrentValue LocationLife Insurance (Group, Term & Whole Life)Owner: ________________________Insured _______________________________Beneficiary_____________________________________________________________Company ______________________________________Policy No. _______________Cash Value _____________________Face Value ___________________________Owner: ________________________Insured _______________________________Beneficiary_____________________________________________________________Company ______________________________________Policy No. _______________Cash Value _____________________Face Value ___________________________Miscellaneous Assets (Nursing Home Patient Account, Business, HSA Account, etc.)Description of AssetOwner(s)Purchase PriceCurrent Value LocationTrusts & InheritancesAre you or your spouse the beneficiary of any trust? Yes ______No ______If Yes, name & address of the Trustee ____________________________________What percentage is your share of the trust? ________ How much do you receive in distributions? ______ How often does the Trustee make the distribution? ______Do you or your spouse expect an inheritance? Yes _____No ______If yes, how much: _____________When? ___________________LIABILITIESDescriptionBalance DueMonthly PaymentMaturity DateMONTHLY INCOMESourceYouJointSpouseSocial Security RetirementSocial Security Disability Income (SSDI)Supplemental Social Security Income (SSI)Pension(s) from WorkVA Benefits/PensionIRAsAnnuitiesInterest Income (Banks)DividendsBusiness IncomeEmploymentRental IncomeOther IncomeTOTALSLEGALLocation of important papers:__________________________________________DocumentAgent Contact InfoDate MadeLast Will & TestamentExecutor:Durable Power of AttorneyAgent:Appointment of Health Care RepresentativeRepresentative:Revocable TrustTrustee:Special Needs TrustTrustee:Designation of ConservatorConservator:Do you have a conservator of your estate? Yes ____ No _____ If yes, is it a voluntary conservatorship or an involuntary conservatorship? _________________________________Probate Court: ______________________________ Date Appointed: ___________Contact Info for conservator: ___________________________________________________Do you serve as conservator, power of attorney, executor for anyone?Title of Position: __________________________________________________Name of the person: _______________________________________________Address: ________________________________________________________Phone: _____________Date service started: _______________Probate Court that appointed you: ____________________________________Are you involved in any lawsuits? ________ Date lawsuit started _________Your attorney contact info _______________________________________________________Anticipated settlement amount: ____________________Have you ever lived in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA, WI) while married? If so, list state(s)___________________________________________________PREPARATION FOR INITIAL MEETINGPlease bring copies of the following documents with you to your initial meeting with the attorney:Will, Codicil, Trust AgreementsDurable Power of Attorney, Appointment of Health Care Representative, Designation of Conservator, Disposition of Remains, Living Will Real estate deeds, appraisalsConservatorship documentsCaregiver AgreementsDivorce decrees, premarital agreements, adoption papersAdmission agreements to hospitals or nursing homesMilitary Discharge papersBrokerage account statementsProof of disability, if indicated.Contact Information of all Caregivers (other than children):NAMEADDRESSE-MAILPHONEComments or other legal concerns:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download