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Referred by (name):
Company:
Date:
*Please put N/A for not applicable rather than leaving items blank.
Client Contact Person
Full Name
Email Mobile #
Fax # Home #
Mailing Address City, State Zip
Are You the agent named under the Power of Attorney?
Relation to client
Nursing Facility Info (IMPORTANT)
Name
Monthly Cost
Date of Entry
Previous Facility Stay Yes No
Is Spouse in a Facility? Yes No
Client (Resident)
Full Name
SSN
DOB
US Citizen? Client: Yes No / Spouse: Yes No
Home Address (prior to facility)
City, State Zip
Single:
Married:
Widowed:
Divorced:
Are you or your spouse a Veteran? Yes No
Existing Estate Planning: Client Spouse Date Created
Power of Attorney
Health Care Directives
Guardianship
Trust:
Revocable
Irrevocable
None




Long-Term Care Insurance Daily Benefit: $
Client's Spouse (if applicable)
Full Name
SSN
DOB
Children
Client Spouse
Do you have children? Yes    How Many? No Yes    How Many? No
Please Specify Joint    Step    Adopted    Foster Joint    Step    Adopted    Foster
Bring the last 3 months statements through current date for ALL financial accounts listed to the Initial Consult Meeting
The elder law practice
CLIENT ASSET PRESERVATION FORM (cont.) FAX (888) 898-9606 PHONE (501) 843-9014 WEBSITE arkelderlaw.com
MONTHLY INCOME CLIENT SPOUSE
Social Security $ $
Pension $ $
VA $ $
Other: $ $
Other: $ $
ASSETS (CURRENT VALUE) Circle all that apply IN CLIENT/JOINT NAME IN SPOUSE NAME
Cash, Checking, Savings, CD's, Money Market, etc. $ $
Brokerage Accounts $ $
Qualified Accounts: IRA, 401K, 403B, SEP, etc. $ $
Annuities: (current value) $ $
Home Address: Value: $ Owner:
Other Real Estate Please List Address or County of Property, Mineral Rights, Oil/Gas Lease, Etc.
Value:$ Owner:
Value:$ Owner:
Other Assets Please List Assets Not Accounted For Above (ex.Vehicles, Tractor, Boat, Airplane, Gold Bars, Etc.)
Value:$ Owner:
Value:$ Owner:
Value:$ Owner:
LIABILITIES (debt other than home) IN CLIENT/JOINT SPOUSE
Credit Cards $ $
Vehicle Loans $ $
Other $ $
INSURANCE (Life, Medicare Supplement, Part D, Burial/Funeral, Etc.)
Owner? Client (C) or Spouse (S): |C| |S|
Medicare Supplement
Co. Name: Policy#: Premium: $
Co. Name: Policy#: Premium: $
Part D Prescription
Co. Name: Policy#: Premium: $
Co. Name: Policy#: Premium: $
Life Insurance
(add line) 
Co. Name: Policy#:
Premium: $ Cash Value: $
Prepaid Burial/Funeral
(add line) 
Co. Name: Policy#:
Premium: $ Cash Value: $
Other
(add line) 
Co. Name: Policy#:
Premium: $ Cash Value: $
TRANSFERS
Have you given money or resources to a family memeber within the last five years? (Include any gift of $100 or more)

Yes No
List Recipients Value & Date of Gift
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IF NECESSARY, PLEASE USE THE INPUT FIELD BELOW TO PROVIDE INFORMATION ABOUT ANY OTHER ADDITIONAL INCOME, ASSETS, INSURANCE POLICIES, TRANSFERS, ETC.
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