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Long-Term Care

PERSONAL INFORMATION

Your Information

Do you have the following

Does your Spouse/Partner have the following?

Your health plays an important role in designing an estate plan best suited for you and your loved ones.

Client - Current Health

Spouse – Current Health

Please use the space below to provide any other information you feel may be helpful to us.

Who may we thank for referring you to our office?

FAMILY INFORMATION

Please list all Children, Living and Deceased
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse

INCOME

List regular sources of gross monthly income and amounts (do not deduct taxes, Medicare premiums, etc):

GIFTS AND TRANSFERS

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