Intake Questionnaire

Step 1 of 6

Financial – Income
For each income type enter the amount of the GROSS MONTHLY INCOME (before any tax or medical insurance deductions). If married list each income source separately.
Social Security Monthly Income (enter the amount before deductions)*
Applicant Monthly Social Security Spouse Monthly Social Security
Are Income Taxes Deducted from the Applicant's Social Security?*
- Yes
- No
- I don’t know
- N/A – does not have Social Security
If yes to above enter the exact dollar amount of taxes withheld from the Applicant's Social Security benefits
Supplemental Security Income (SSI)
Applicant SSI Benefit Amount Spouse SSI Benefit Amount Applicant Claim Number Spouse Claim Number
Retirement Pension (i.e. from a previous employer)
Do not Enter IRA’s or 401(k) here. Enter Gross Pension Amount (before health insurance or tax deductions)
Applicant – gross monthly pension Applicant – name of pension company Spouse – gross monthly pension Spouse – name of pension company If pension is not paid monthly enter how often paid
Are Income Taxes Deducted from the Applicant's Retirement Pension?
- Yes
- No
- I don’t know
If yes to above enter the exact dollar amount of taxes withheld from pension
Railroad Retirement Benefits
Applicant Benefit Amount Spouse Benefit Amount Claim Number

Annuities – enter only privately held annuities; not "annuity pensions" from previous employment)

Enter the name of the annuity provider, which should be an insurance company. All other types of annuities should be listed under “Retirement Pensions” above

Applicant – Annuity Income Amount	Applicant – name of annuity provider	Applicant – how often payments received	Spouse Annuity Income Amount	Spouse – name of annuity provider	Spouse – how often payments received

Rental Income
Monthly rent received Who receives the rent payments? Type of Property Any additional details regarding this rental property?
Capital Gains
Capital gains are profits from the sale of an asset (such as stock shares, property, a business, etc). This income would have been reported to the IRS & the owner of the asset must be provided with tax form 1099. Please enter the amount(s) from form 1099 (or the amount(s) on the most recent federal tax return).
Applicant annual gains Spouse annual gains Additional comments
Worker's Compensation
Applicant monthly benefit amount Spouse monthly benefit amount Additional comments
Gambling Income
Applicant Income Received Spouse Income Received Comments
Farm Income
Applicant Income Received Spouse Income Received Comments
Unemployment Benefits
Applicant Income Received Spouse Income Received Comments
Compensation from a legal settlement
Applicant – How much received? Spouse – How much received? Date of settlement What was the settlement for?
Other Income
Applicant Amount Received Spouse Amount Received Comments

Save and Continue Later

Name of Owner(s)	Type of account & Account Number	Current Value	Date of most recent balance

Intake Questionnaire

Step 1 of 6

Service Agreement Consent

Representative's General Information

Applicant's General Information

Spouse's General Information (if not currently married skip to the next section)

Legal Information

Health Insurance Premiums

Life Insurance Policies

Financial – Income

Financial – Property

Financial – Checking & Savings Accounts

Financial – Retirement & Other Investment Accounts

Financial – Pre-Paid Funeral/Burial

Financial – Living Expenses

Financial – Medical & Care Expenses

Financial – Asset Transfers

Discontinued Assets

Liabilities (debt, loans, etc.)

Tax Information

Care & Medical

Annual Renewal Consent