Questionnaire Three · Elder Law & Medicaid

Let’s Protect What a Lifetime Built

Whether care is years away or the discharge planner called this morning, these questions let us see your family’s position clearly. Answer what you can — approximate values are fine, and adult children are welcome to complete this for a parent.

Who Is This About?

Your full name *

Your relationship to the person needing care

Your email *

Your phone *

Name of the person needing care

Their age

Their marital status

City & county in Florida

The Care Situation

Where is care needed, or expected? *

How urgent is this? *

Briefly, what is the health situation?

Children & Decision Makers

List the elder’s children and anyone who will be part of decisions. Include each child’s full name, date of birth, and home address. One child living in the home can matter to the plan, so we ask.

Child 1

Full legal name

Date of birth

Home address

Does this child live in the elder’s home?

Is there a durable power of attorney in place?

Exempt Assets

Florida Medicaid does not count certain assets. Approximate values are fine.

Florida homestead — approximate value

Primary vehicle — approximate value

Prepaid burial / funeral arrangements

Other exempt assets (describe & value)

Countable Assets

These are the assets exposed to spend-down without planning.

Bank accounts / CDs

Brokerage / investments

Cash value of life insurance

Other real estate (not the homestead)

Other countable assets (describe & value)

Retirement Accounts & Income

IRA / 401(k) / retirement — approximate total

Are regular withdrawals being taken?

How often are withdrawals taken?

Gross monthly income of the person needing care

If married: spouse’s gross monthly income

History & Anything Else

Any gifts or transfers of money or property in the last 5 years?

Is the elder (or their late spouse) a wartime veteran?

Anything else we should know?

Your answers are sent securely and confidentially to attorney Evan W. Turk. Submitting this questionnaire does not create an attorney-client relationship; that relationship is formed only by a signed engagement agreement. Please do not include Social Security numbers or account numbers. Privacy policy.