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Please start your questionnaire below. A Zacharia Brown Elder Law Attorney will review your information and email an assessment of your questionnaire that highlights any possible planning areas where we may be of assistance.

    1. Are you over 65 years of age?

    2. Are you married?

    2a. Do you have financial assets in excess of $25,000?

    2b. Does a spouse in the nursing home have an IRA, 401K, 403B or other retirement account?

    2c. Does a spouse NOT in the nursing home have an IRA, 401K, 403B or other retirement account?

    2d. Does a spouse NOT in the nursing home have monthly income of at least $2058?

    2e. At time of a nursing home admission, were the spouses living apart?

    2a. Do you have financial assets in excess of $30,000?

    3. Do you own a home?

    3a. Do you have a mortgage or pay rent?

    4. Do you have additional debts or liabilities (i.e. credit cards, car loans, etc.)?

    5. Do you have real estate other than your primary residence?

    6. Do you live with a child in that child's home?

    7. Do you have a child who resides in your home?

    7a. Has the child resided in the home for 2 years or more?

    7b. Is that child's name on the deed?

    8. Do you have a child with a disability?

    8a. Is your child with the disability on Medicaid / Medicare?

    9. Do you have a business or business-related property?

    10. Have you made any gifts (cash, real estate or other assets) in excess of $500 per month in the last 60 months?

    11. Have you paid cash for goods or services, for example, caregivers, in an amount over $500 in a calendar month?

    12. Have you made large withdrawals of cash, over $500 in a calendar month?

    13. Have you previously resided in another Nursing facility?

    13a. If yes, what were the dates of your prior admission?

    14. Do you have a Last Will & Testament?

    15. Do you have Durable Financial Power of Attorney?

    16. Do you have a Durable Medical Power of Attorney and Living Will?

    17. Do you have a Revocable Living Trust?

    18. Do you have a Irrevocable Living Trust?

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