Law Offices of John J. Campbell, P.C.
An Elder Law Firm
Client Questionnaire Please fill out the requested information to the best of your ability. If you do not know the answer to a question or if the question does not apply, just leave it blank. By completing and submitting this questionnaire before your appointment, you will allow us to serve you more efficiently and economically.
Note: If you are filling out this questionnaire for someone else, we need that person's information as the "client."
Your information will submitted over our 128-bit encrypted, SSL secure connection and will be kept confidential. We will not share with anyone without your permission.
Form: Client Questionnaire
Client Name:
Street Address:
City, State, Zip:
Client E-Mail Address:
Daytime Telephone:
Evening Telephone:
Date of Birth:
Employer:
Retirement Date:
U.S. Citizen? Yes No
Veteran? Yes No
Are You Married? Yes No
Date of Marriage:
Spouse's Name:
Your Family:
Do You Have Children With Your Spouse? Yes No
Names, Addresses, Telephone Numbers and Dates of Birth of Your Children:
Do You or Your Spouse Have Children From a Previous Marriage? Yes No
Names, Addresses, Telephone Numbers and Dates of Birth of Your Children from Previous Marriage:
Do You Have Grandchildren? Yes No
Names, Addresses, Telephone Numbers and Dates of Birth of Your Grandchildren:
Is Anyone in Your Family Disabled? Yes No
Name and Nature of Disability:
Does Anyone In Your Family Receive any of These Public Benefits:
Social Security Retirement: Yes No
Railroad Retirement: Yes No
Social Security Disability Insurance (SSDI): Yes No
Supplemental Security Income (SSI): Yes No
Medicare Part A: Yes No Medicare Part B: Yes No
Medicare Part C (Medicare Advantage): Yes No
Medicare Part D (Rx Benefits): Yes No
Medicaid: Yes No
Veteran's Benefits: Yes No
Health Coverage for Veteran's, Families or Survivors: Yes No
Does Anyone in Your Family Require Assistance with Medical or Financial Decision-Making? Yes No
Name:
Has Anyone in Your Family Been Diagnosed with Alzheimer's or any Other Form of Dementia? Yes No
Is Anyone in Your Family in a Nursing Home or Assisted Living Facility? Yes No
Does Anyone in Your Family Expect to Require Care in a Nursing Home or Assisted Living Facility in
the Future? Yes No
Does Anyone in Your Family Require Attendant or Custodial Care Services in the Home? Yes No
Your Estate Planning Documents:
Do You Have a Will? Yes No Does Your Spouse? Yes No
Do You Have a Financial
Power of Attorney? Yes No Does Your Spouse? Yes No
Do You Have a Medical
Do You Have a Living Will? Yes No Does Your Spouse? Yes No
Do You Have a Living Trust? Yes No Does Your Spouse? Yes No
Your Health Insurance Coverage:
Group Health Insurance:
Do You Have Group Health
Insurance Coverage? Yes No Does Your Spouse? Yes No
1. Name of Insurer:
Policy Number:
Is This Coverage Available Through an Employer? Yes No
Name of Employer:
Name of Employee:
Is This Coverage Available Through a Former Employer as a Retirement Benefit? Yes No
Name of Former Employer:
Name of Retiree:
2. Name of Insurer:
Medicare Supplemental Insurance:
Do you own a Medigap policy? Yes No Does Your Spouse? Yes No
Type of Policy (A-J): Select One A B C D E F G H I J Type of Policy (A-J): Select One A B C D E F G H I J
Name of Insurance Company: Name of Insurance Company:
Policy Number: Policy Number:
Other Health Insurance:
Please describe any other health care insurance, including the name of the insured, the name of the insurance company, the policy number, and the type of coverage provided:
Your Property & Assets:
Do You Own a Home? Yes No
Name(s) on Title:
Address, City, State, Zip:
Market Value: $
Is There a Mortgage? Yes No Current Balance: $
Is There a Reverse Mortgage? Yes No Current Balance: $
Do You Own Any Other Real Estate? Yes No
Do You Have any Checking or Savings Accounts? Yes No
1. Name of Financial Institution:
Name(s) on Account:
Type of Account: Select One Checking Savings CD Money Market Other
Account Number:
Current Balance: $
2. Name of Financial Institution:
3. Name of Financial Institution:
4. Name of Financial Institution:
Do You Have Any Investment or Brokerage Accounts? Yes No
Type of Account: Select One Money Market Mutual Fund Government Securities Account Stock Account Bond Account Other
Do You Own Any IRA's, 401k's or Other Retirement Accounts? Yes No
Type of Account: Select One IRA Roth IRA 401k Keogh Pension Plan Other
Do You Own Any Annuities? Yes No
1. Name of Issuing Insurance Company:
Owner:
Payee:
Death Beneficiary:
Current Value: $
Are You Receiving Payments From Your Annuity? Yes No
How Often? Payment Amount: $
2. Name of Issuing Insurance Company:
3. Name of Issuing Insurance Company:
4. Name of Issuing Insurance Company:
Do You Own Any Life Insurance Policies? Yes No
Name of Insured:
Beneficiary:
Death Benefit Amount: $
Does Your Policy Have a Current Cash Value? Yes No
Cash Value Amount: $
Do You Own Any Vehicles? Yes No
1. Type of Vehicle: Select One Car Pick-up Truck Van or Mini-Van Motorcycle Other
Make, Model & Year:
2. Type of Vehicle: Select One Car Pick-up Truck Van or Mini-Van Motorcycle Other
3. Type of Vehicle: Select One Car Pick-up Truck Van or Mini-Van Motorcycle Other
4. Type of Vehicle: Select One Car Pick-up Truck Van or Mini-Van Motorcycle Other
Do You Have Pre-Paid Burial Insurance? Yes No
1. Name of Issuing Company:
Amount: $
Is Your Policy Irrevocable? Yes No
2. Name of Issuing Company:
Have You Made Any Other Arrangements for Burial or Cremation? Yes No
Describe:
Do You Own A Business? Yes No
Name of Business:
Business Telephone:
Describe the Type of Business:
Business is Organized as a: Select One Corporation S Corporation Professional Corporation Partnership Limited Partnership Limited Liability Company Limited Liability Partnership Limited Liability Limited Partnership Sole Proprietorship Other
Current Value of Business: $
How Many Employees?
Year You Started the Business:
Names and Addresses of any Other Owners:
Other Assets:
Please list any other assets, the name(s) of the owner(s), location of the assets and their current value:
Your Income:
Please list your average current monthly income from each of the following:
Social Security or Railroad Retirement: $
SSDI: $
SSI: $
Veteran's Benefits: $
Retirement or Pensions: $
Other (describe ): $
Please list your spouse's average current monthly income from each of the following:
Other Comments or Concerns:
If you have any other comments or concerns, please describe them here:
Documents to Bring With You:
Please bring as many of the following documents as you can with you to your appointment:
❒ Financial Documents ❒ Stock and Bond Certificates ❒ U.S. Savings Bonds ❒ Certificates of Deposit ❒ Checking Account Statements (most recent) ❒ Deeds to Real Property, Homes, etc. ❒ Insurance Policies (Including Life, Group Health, Medigap and Long Term Care ❒ Savings Account Statement (most recent) ❒ Stocks and Brokerage Account Statements (most recent) ❒ Titles to Vehicles, Accounts, etc. ❏ Value of Cars ❏ IRA, 401K, Keogh and Pension Account Statements (most recent) ❏ Social Security, Railroad Retirement, SSDI, SSI or VA Benefit Statements (most recent) ❒ Burial Policies ❒ Living Wills ❒ Financial and Medical Powers of Attorney ❒ Trusts ❒ Wills ❒ Family Owned Corporation, Limited Partnership or Limited Liability Company Documents ❒ Other Estate Planning Documents ❒ Social Security Card, Medicare Card and/or Medicaid Card ❒ Date of Birth ❒ Names, Addresses, and Phone Numbers of Immediate Family Members ❒ Doctor’s Letter of Diagnosis (if available)
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