This form is extremely important. Your accuracy and completeness in responding will help me best represent you. Please bring this information with you to the appointment.
Date_________________________________ File No. _________________________________
A. CONTACT PERSON
Full Name __________________________________________________________________
Street Address __________________________________________________________________
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No. ________________________
E-mail Address ___________________________ Fax No. ________________________
Version of Software: WordPerfect Word Other
B. PROTECTED PERSON
Name of Ward (person to be protected)
Permanent Address (domicile)
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Date of Birth ________________________
Current Place of Residence: Home Nursing Home Hospital
Is it anticipated that proposed Ward will remain at current address for the next six (6) weeks?
Yes
No (please provide the anticipated address below)
Facility Name (if applicable)
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
C. PROPOSED GUARDIAN(S)
1. Proposed Guardian
(if same as Contact Person, complete date of birth and relationship to ward sections only)
Full Name
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Version of Software: WordPerfect Word Other
Date of Birth
Relationship to Ward or Interest in Proceedings
2. Proposed Co-Guardian
Full Name
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Version of Software: WordPerfect Word Other
Date of Birth
Relationship to Ward or Interest in Proceedings
D. REFERRAL
By Whom Were You Referred To This Office?
Full Name
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
E. NAMES AND ADDRESSES OF PERSONS ENTITLED TO NOTICE OF HEARING
1. Ward's Spouse
Full Name
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
2. Ward's Father (if living)
Full Name
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
3. Ward's Mother (if living)
Full Name
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
4. Ward's Children (if applicable)
Full Name of Wards Son Daughter
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
Full Name of Wards Son Daughter
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
Full Name of Wards Son Daughter
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
Full Name of Wards Son Daughter
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
Full Name of Wards Son Daughter
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
Full Name of Wards Son Daughter
Street Address
City __________________________________ State ___________________ Zip
Home Phone No. ________________________ Business Phone No.
E-mail Address ___________________________ Fax No.
Date of Birth
5. Administrator of Nursing Home in Which Ward is Living (if applicable)
Name of Nursing Home
Name of Administrator
Name of Social Worker
Street Address (if other than as indicated in Section B)
City __________________________________ State ___________________ Zip
Business Phone No.___________________________ Fax No.
E-mail Address
Date of Admission to Nursing Home (if applicable)
Name of Hospital prior to Nursing Home Admission (if applicable)
Date of admission to Hospital prior to Nursing Home Admission (if applicable)
Reason for admission to Hospital (if applicable)
F. REASON PROPOSED WARD NEEDS A GUARDIAN
Diagnosis
Date of Diagnosis
Examples of Incapacity
G. MEDICAL
Name of Physician Making Diagnosis
Street Address
City __________________________________ State ___________________ Zip
Business Phone No.___________________________ Fax No.
E-mail Address
Name of Second Proposed Examining Physician
Street Address
City __________________________________ State ___________________ Zip
Business Phone No.___________________________ Fax No.
E-mail Address
H. SUMMARY OF INCOME
Please list estimated income and expenses for the current year from the following sources.
Monthly Amounts
Ward Spouse
Social Security
Pension Benefits
IRA Income
Disability Income
Rental Income
Interest Income
Dividends Income
Annuity Income
Other
Other
TOTAL _________________ _________________
I. MONTHLY SHELTER EXPENSES
(Please divide annual expenses by 12 and quarterly expenses by 3)
Rent/Mortgage $_________________________
Real Estate Taxes $_________________________
Water $_________________________
Sewer $_________________________
Utilities (Heat, Electric & Telephone) $_________________________
(1/12th of last 12 months)
Homeowners insurance premium $_________________________
Condominium fees $_________________________
Total Monthly Housing Expenses $_________________________
J. MONTHLY NON-SHELTER LIVING EXPENSES
Food $_________________________
Medical $_________________________
Clothing $_________________________
Transportation (including auto insurance) $_________________________
Home Maintenance $_________________________
Life Insurance Premiums $_________________________
Health Insurance Premiums $_________________________
Cable TV $_________________________
Federal and State Income Taxes $_________________________
Other $_________________________
Total Monthly Non-Shelter Living Expenses $_________________________
K. REAL ESTATE
1. Tax Block _____________________________ Lot
Municipality____________________________ Assessed Value $
Market Value $_________________________(apply reciprocal of equalization ratio)
2. Tax Block _____________________________ Lot
Municipality____________________________ Assessed Value $
Market Value $_________________________(apply reciprocal of equalization ratio)
3. Tax Block _____________________________ Lot
Municipality____________________________ Assessed Value $
Market Value $_________________________(apply reciprocal of equalization ratio)
L. MEDICAID
Does the proposed ward receive Medicaid? Yes No
If so, provide date Medicaid benefits began
M. LIFE INSURANCE
1. Name of Company
Policy No. ____________________________ Face Amount of Policy $
Beneficiary
2. Name of Company
Policy No. ____________________________ Face Amount of Policy $
Beneficiary
3. Name of Company
Policy No. ____________________________ Face Amount of Policy $
Beneficiary
N. AUTOMOBILE
Make___________________________________ Model
Year ____________________ Estimated Resale Value $
O. PERSONAL EFFECTS
Estimated Value $
P. FINANCIAL SUMMARY
ASSETS/LIABILITIES
Please insert the value of each asset/liability in the appropriate space.
|
ASSETS |
HUSBAND |
WIFE |
JOINT |
LIABILITIES |
|
PERSONAL EFFECTS |
||||
|
AUTOMOBILE |
||||
|
CHECKING ACCOUNT |
||||
|
SAVINGS ACCOUNT |
||||
|
MONEY MARKET ACCOUNT |
||||
|
CERTIFICATES OF DEPOSIT |
||||
|
RESIDENCE (ASSESSED VALUE) BLOCK#__________ LOT#________ (Obtain from Tax Bill) |
||||
|
OTHER REAL ESTATE |
||||
|
ADDITIONAL AUTOMOBILES |
||||
|
MUTUAL FUNDS |
||||
|
STOCKS |
||||
|
BONDS |
||||
|
ANNUITIES |
||||
|
CASH VALUE - LIFE INSURANCE |
||||
|
IRA |
||||
|
NURSING HOME DEPOSIT |
||||
|
OTHER |
||||
|
OTHER |
||||
|
TOTALS |
Q. MONTHLY COST OF NURSING HOME
Monthly Nursing Home Cost $_________________________
Monthly Prescription Cost $_________________________
Monthly Incontinent Cost $_________________________
Monthly Other Cost $_________________________
Total Monthly Cost $_________________________
The nursing home is paid through ________________________________________(month/year).
R. CERTIFICATION
The undersigned hereby represents to Roy W. Wilkes, Esquire The Elder & Disability Law Firm, and each of its attorneys that the information contained in this intake form is accurate and complete, and that the undersigned understands that the law firm and its individual lawyers will rely on this information. I understand that if the information contained herein is inaccurate or incomplete, the recommendations made by the law firm may not be appropriate.
Signature of Client/Client Representative: ______________________________________________________