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A. PERSONAL INFORMATION
Date of Birth: Social Security Number:

Name of client:
Spouse:
Address:

Telephone: Home: _________ Business:
Military Service: _________ Citizenship:
Status of Health: (client)
(spouse)

Client's Objectives: _______________ _______________ _______________
Contact Person: Relationship: _________
Address:                                                                                     
Telephone: Home: _________ Business:                                            
Fax:______________________________

NOTE: Also, please bring the following Documents to our meeting, if available and applicable: (a) Will(s), (b) Power(s) of Attorney, (c) deed(s) to residence and other real property (with recent real estate tax bills), (d) last two years tax returns, (e) life and health insurance policies and (f) any other documents or information you deem relevant.
Office Use Only Matter No.: __________________ Date:___________________________

B.    MARITAL INFORMATION
Date and Place of Marriage:
Has either of you been married previously?
If yes, give each prior spouse's name and address; date of death, or divorce from prior spouse; the title, location, and case number of probate or divorce court:

__________________________________________________________________________________

C. CHILDREN AND GRANDCHILDREN
Children of present marriage (living and deceased). Indicate if adopted, and give the date adopted and the court granting adoption order. (Indicate if deceased by putting "D" and give date of death next to name.) Please indicate whether any deceased child left any surviving children.

Name                          Address                                 Birthdate             Spouse

__________________    _______________________    ______________    __________________

__________________    ________________________    ______________    __________________

__________________    ________________________    ______________    __________________

__________________    ________________________    ______________    __________________

Husband:    Children of a prior marriage to _______________ _______________ _______________
Wife:   Children of a prior marriage to _______________ _______________ _______________
Grandchildren:  ________________  _____________________  _________________

Name                               Address                                      Birthdate                 Spouse

__________________    ________________________    ______________    __________________

__________________    ________________________    ______________    __________________

__________________    ________________________    ______________    __________________

__________________    ________________________    ______________    __________________

Please list parents, brothers, sisters, grandparents, and others (if relevant). Please note if any of those listed are dependent on you for support.

D. GENERAL INFORMATION
Client/ Spouse
Yes/No

* Do you receive Social Security? _________________
If so, where is your check deposited? _________________
Is the check directly deposited by Social Security? _________________
* Are you self-employed? _________________
* Have you been appointed to a fiduciary status (executor, trustee, attorney-in-fact, etc.) under any legal documents _________________
If so, please describe said documents ._________________
* Are you involved in a law suit? _________________
If so, please explain _________________
* Do any family members require special attention? (Explain; use back page, if necessary). Think, for example, about their health and general financial status, including needs and prospects.
* Is anyone in your family disabled? _________________
* Is anyone at risk because of medical condition or family history for becoming seriously ill or disabled?_________________
* If you were in the hospital and unable to make decisions for yourself, with whom would you want your doctor to consult with about your care (in priority order)? _________________
* If you were unable to carry out your financial business, whom would you want to pay bills, make investment decisions and carry out other transactions for you? _________________

E. HEALTH CARE INFORMATION
Do you have
* Medicare? Part A _________ Part B _________ Part C_________________
* Supplemental Medicare Insurance ____________________________________________
* Are you enrolled in a Medicare HMO? _________________

Long Term Care Insurance ____________________________________________________

* Do you receive Medicaid Benefits? _________________
* Do you receive Veterans Benefits? ._________________

F. DOCUMENTS
Client/ Spouse
Yes/No

Do you have a will? _________________
Date of will? _________________
Date of last review? _________________
Do you have a Durable Power of Attorney? _________________
Do you have a Health Care Proxy? _________________
Do you have a Living Will? _________________
Do you have a Living Trust? _________________

G. GIFTS YOU HAVE MADE
Include gifts made between 1932 and 1981 in excess of $3,000 per year per donee. Include gifts made since 1981 in excess of $10,000 per year per donee.

Send mail to maberasturi@yahoo.com with questions or comments about this web site.
Last modified: 12/21/06

Mark G. Aberasturi, a New York elder law lawyer and estate planning attorney, focuses his law practice on Elder Law and Probate, Estates, Wills and Medicaid Trusts, Living Trusts, Supplemental Needs Trusts, Living Wills and Estate Tax.  Mr. Aberasturi provides legal advice on matters involving Medicaid, Medicare and nursing homes.  Mr. Aberasturi is a member of the National Academy of Elder Law Attorneys, The New York State Bar Association Elder Law Section, and is former chairman of the Orange County, New York Bar Association Elder Law Committee.  His practice is located in Goshen, Orange County New York.

 

Servicing the Hudson Valley area, including Monroe New York 10950, Montgomery New York 12549, Middletown New York 10940 and 10941, Newburgh New York 12550, Wallkill New York 12589, Washingtonville New York 10992, Chester New York 10916, Port Jervis New York 12771, New Windsor New York 12553, Cornwall New York 12518, Central Valley New York 10917, Highland Mills New York 10930, Florida New York 10921, Walden New York 12586, Warwick New York 10990, and Maybrook New York 12583, Tuxedo Park 10987, Blooming Grove 10914, Circleville 10919, Fort Montgomery 10922, Harriman 10926, Pine Bush 12566, New  Hampton 10958, Slate Hill 10973, as well as Ulster County, Sullivan County and Rockland County.