Complete Estate and Medicaid Planning Questionnaire         Estate Planning Client Asset Information  

As an option, the "Estate and Medicaid Planning Questionnaire" may be completed below and submitted directly to the Law Office of Timothy J. Rice, Esq. Please print and complete the "Estate Planning Client Asset Information" form and bring it with you for your first visit.

ESTATE & MEDICAID PLANNING QUESTIONNAIRE
YOUR NAME: (required)	First	MI	Last
a/k/a (if any)
SPOUSE (if applicable):	First	MI	Last
a/k/a (if any)
HOME ADDRESS: (required)
HOME PHONE NUMBER: (required)
YOUR EMAIL ADDRESS:  (See note at bottom of this form)
YOUR OCCUPATION:
Employer's Name & Address
Work Telephone No.
SPOUSE'S OCCUPATION:
Employer's Name & Address
Work Telephone No.
CHILDREN (IF APPLICABLE)
CHILD #1	Name
	Age		Marital Status
	Address
	Born of this marriage   or prior Marriage
CHILD #2	Name
	Age		Marital Status
	Address
	Born of this marriage   or prior Marriage
CHILD #3	Name
	Age		Marital Status
	Address
	Born of this marriage   or prior Marriage
CHILD #4	Name
	Age		Marital Status
	Address
	Born of this marriage   or prior Marriage
GRANDCHILDREN (IF APPLICABLE)
GRANDCHILD #1	Name
	Age		Marital Status
	Address
	Name of parent
GRANDCHILD #2	Name
	Age		Marital Status
	Address
	Name of parent
GRANDCHILD #3	Name
	Age		Marital Status
	Address
	Name of parent
GRANDCHILD #4	Name
	Age		Marital Status
	Address
	Name of parent
ARE ALL OF YOUR CHILDREN AND GRANDCHILDREN IN GOOD HEALTH?   YES     NO
ARE ANY OF YOUR CHILDREN OR GRANDCHILDREN RECEIVING SSI OR OTHER FORM OF GOVERNMENT AID?   YES     NO
DATE OF MARRIAGE:
HAVE YOU ENTERED ANY PRENUPTIAL, POSTNUPTIAL OR PROPERTY SETTLEMENT AGREEMENT WITH YOUR SPOUSE REGARDING DIVISION OF PROPERTY UPON DIVORCE OR DEATH?    YES     NO
IS THIS YOUR FIRST MARRIAGE?   YES     NO If no, please list date(s) and method of termination (death, divorce, annulment) of prior marriages, including name(s) of former spouse(s):
IS THIS YOUR SPOUSE'S FIRST MARRIAGE?   YES     NO If no, please list date(s) and method of termination (death, divorce, annulment) of prior marriages, including name(s) of former spouse(s): If divorced, indicate whether you entered any property settlement agreements with a former spouse:
Are you and your spouse U.S. Citizens?   YES     NO If no, please indicate which spouse is not a U.S. Citizen and country of citizenship:
YOUR SOCIAL SECURITY NUMBER:
YOUR SPOUSE'S SOCIAL SECURITY NUMBER:
YOUR DATE OF BIRTH:
YOUR SPOUSE'S DATE OF BIRTH:
WHO REFERRED YOU TO THE LAW OFFICES OF TIMOTHY J. RICE OR HOW DID YOU LEARN ABOUT US?
WHAT TYPE OF SERVICE ARE YOU INTERESTED IN US PROVIDING FOR YOU?   Estate Planning: Will, Trust, Power of Attorney, Living Will   Advance Medical Directive   Estate or Trust Administration   Medical Planning   Estate Litigation: Will Contests, etc.   Guardianship   Irrevocable Life Insurance and/or Revocable Trusts        ADDITIONAL COMMENTS
PLEASE LIST NAME, ADDRESS, AND TELEPHONE NUMBER:
FAMILY/CORPORATE ATTORNEY:
ACCOUNTANT:
FINANCIAL PLANNER/BROKER:
BANKER:
INSURANCE AGENT:	Homeowners  Auto  Life
Please type the code into the box and click the 'Submit Form' button.

Note: If you provide your email address, we will email a copy of your completed form to you.