Your Name *

First Name

Last Name

Your Phone *

(###)

###

####

Your Relation to the Applicant *

Myself

Family Member

Friend

Other

Applicant Age *

Over 65

Under 65

Applicant Marital Status *

Single

Divorced

Widowed

Married

Applicant Income - Monthly *

Under $8,000

Over $8,000

If applicable, Applicant Spouse's Income - Monthly *

Under $8,000

Over $8,000

NA

SUM of Checking / Savings: *

Under $2,000

Over $2,000

SUM of Investment / Retirement Accounts *

IRAs, CDs, Stock, Bonds

Under $2,000

Over $2,000

Does the Applicant have Life Insurance / Burial Policies? *

Yes

No

Does the Applicant have a House? *

Yes

No

Does the Applicant own more than 1 home or property? *

Yes

No

Does the Applicant own a registered Vehicle? *

Including Car(s), Boat(s), Trailer(s), Tractor(s), Motorcycle(s)

Yes

No

The Applicant does need assistance with activities of daily living *

Activities of Daily Living Examples: Cooking, Bathing, Toileting, Dressing

Yes

No

Does the Applicant have a Trust?

Yes

No

If a Veteran, the Vet served 90 days of active duty, with at least one day during wartime *

Yes

No

NA

I want to be contacted about my results

Yes

No