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Download Will Intake Form
Download Title 19 Form
Home
About Our Firm
Attorney & Staff Profiles
Practice Areas
Medicaid Title 19
Estate Planning
Real Estate Closings
Social Security
Business and Corporate
Personal Injury
Immigration
Probate
Blog
Contact
Forms
Download Will Intake form
Download Title 19 Form
Title 19 Intake sheet
Name of Applicant
(Required)
Maiden name (if any)
Date of Birth
(Required)
MM slash DD slash YYYY
Social Security number
(Required)
Place of birth
(Required)
Home Address
(Required)
If in Nursing Home, name of home
Date of Admission to Nursing Home or Hospital if went to a nursing home prior
MM slash DD slash YYYY
Spouse’s Information ( If applicable)
Spouse’s Name
Maiden name (if any)
Spouse’s Date of Birth
MM slash DD slash YYYY
If widowed, date of death of spouse
MM slash DD slash YYYY
Social Security number
Are any of your children disabled
Address of Spouse
Do you have any children residing at home with you
If so, how long has the child lived with you
Medical insurance Information
Do you receive Medicare Part A? If so , list your premium amount
Do you receive Medicare Part B? If so, premium amount
Do you receive Medicare Part D or have a Medicare Advantage plan? If so, list premium?
Income (List amounts and frequency)
What sources of Income do you and your spouse have?
Social Security? If so list amounts for both spouses?
Pension? If so, list amounts for both spouses?
Contact Person
Contact Phone #
List any other sources of income (amount and how frequency)
Assets
We need a list of all of your assets
Cash on Hand
List amount
Bank Account No
Owner
Checking
List amount
Bank Account No
Owner
Savings
List amount
Bank Account No
Owner
CDs
List amount
Bank Account No
Owner
Money markets
List amount
Money markets
Owner
IRAs or 401Ks
List amount
Bank Account No
Owner
Stocks
List amount
Bank Account No
Owner
Annuity
List amount
Bank Account No
Owner
Contact Person
Contact Phone #
Automobiles
Do you or your spouse own a vehicle? If so, list the type, value and amount of any car loan?
Life Insurance
Do you have any life insurance? If so is it a term policy or does it have a cash value? List all insurance Policies
Real Property
Do you own a home or any other real estate? If so, list the address, value and amount of any mortgage
If you own a home
What is the amount of the yearly property taxes?
What is the cost of your homeowner’s insurance?
Is either spouse a veteran?
Have you given away any of your assets to your children or others in the last five years?
Do any of your children or family have power of attorney for you?
Do you have long term care insurance?
Do you have a prepaid funeral contract?
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