Date
-
Month
-
Day
Year
Date
A. PERSONAL DATA
(Self)
Full Name
(Print name as shown on your checks)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone No.
Business Phone No.
Cell Phone No.
Fax No.
Email Address
example@example.com
Birth Date
-
Month
-
Day
Year
Date
Social Security Number
U.S. Citizen?
Yes
No
Annual Income
Are you married?
Yes
No
Name of Spouse
Do you have a legal guardian?
Yes
No
Your Medical diagnosis is:
Your treating physician:
Are you employed?
Yes
No
Monthly income from employment
Are you receiving public benefits?
Yes
No
Monthly income from public benefits
The public benefits you are receiving or are likely to apply for are:
SSI
Medicare
Group Home
Medicaid
Medicaid Waiver
Psychiatric
SSD
Section 8 Housing
Institutionalization
Other Public Benefits
Is there a case worker involved?
Yes
No
Name and address of caseworker:
If you are not receiving public benefits, has there been a determination of disability by the Social Security Administration?
Yes
No
Are the assets to fund the trust of a parent or other third party?
Yes
No
Trustee will be a:
Family Member
Professional Trustee
Have you or will you be receiving a settlement from a law suit?
Yes
No
If yes, amount of settlement
Is there legal counsel involved?
Yes
No
Name of legal counsel
B. ESTATE PLANNING DOCUMENTS
1. The disabled person has a:
Will
Health Care Power of Attorney
Trust
Living Will
Financial Power of Attorney
2. Non-parent family members have:
Will(s)
Health Care Power(s) of Attorney
Third-Party Special Needs Trust
Financial Power(s) of Attorney Living Will(s)
Living Will(s)
Revocable Living Trust(s)
I. PARENTS
Do you have living parents? If yes, please check the applicable boxes:
Yes
No
If yes to living parents, please answer the fields below:
NY Resident?
Resident?
Age?
Mother
Father
II. REMAINDER BENEFICIARIES OF THE TRUST
#1.) Name
First Name
Middle Name
Last Name
Gender
Relationship to Disabled SNT Beneficiary
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone No.
Fax No.
Email Address
example@example.com
Cell No.
Birth Date
-
Month
-
Day
Year
#2.) Name
First Name
Middle Name
Last Name
Gender
Relationship to Disabled SNT Beneficiary
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone No.
Fax No.
Email Address
example@example.com
Cell No.
Birth Date
-
Month
-
Day
Year
#3.) Name
First Name
Middle Name
Last Name
Gender
Relationship to Disabled SNT Beneficiary
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone No.
Fax No.
Email Address
example@example.com
Cell No.
Birth Date
-
Month
-
Day
Year
III. CHARITIES
Do you want to leave a specific amount of money or other assets to any charity?
Yes
No
If yes, please list charity information below:
Name of Charity
Address of Charity
Dollar Amount
1.
2.
3.
Name of Charity
IV. LIFE INSURANCE/LONG TERM CARE INSURANCE
#1.) Name of Company
Policy #
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Policy
Owner
Insured
Beneficiary
Death Benefit
Face Value
Cash Value
#2.) Name of Company
Policy #
Policy #
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Policy
Owner
Insured
Beneficiary
Death Benefit
Face Value
Cash Value
V. Possible Trustees
Would you consider a corporate or non-profit Trustee?
Yes
No
Potential Individual Trustees:
#1.) Full Name
First Name
Middle Name
Last Name
Gender
Relationship to Disabled SNT Beneficiary
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone No.
Fax No.
Email Address
example@example.com
Cell No.
Birth Date
-
Month
-
Day
Year
Gender
#2.) Full Name
First Name
Middle Name
Last Name
Gender
Relationship to Disabled SNT Beneficiary
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone No.
Fax No.
Email Address
example@example.com
Cell No.
Birth Date
-
Month
-
Day
Year
C. MISCELLANEOUS
What is the location of your important papers?
Do you have a safe deposit box?
Yes
No
If yes, please indicate the name and address of the location:
Have you ever made gifts to any one person in excess of $500 in any one calendar year?
Yes
No
Have you ever filed a federal gift tax return?
Yes
No
D. REFERRAL
By Whom Were You Referred To This Office?
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone No.
Fax No.
Email Address
example@example.com
Cell No.
Referral is a:
Attorney
Disability Organization
Insurance Broker
Trust Company
Financial Advisor
Other
E. YOUR ADVISERS:
Advisers:
Name
Telephone Number
Accountant
Life Insurance Agent
Investment Advisor
Other Attorney
Other Consultant or Advisor
Physician
Service Providers
Best Email to Reach You At:
*
example@example.com
Submit
Should be Empty: