Information for Medicaid Planning Form

The attorneys at Friedman & Ranzenhofer ask their prospective clients to do the best they can in completing the required fields on this intake form and collecting certain items.

Do not feel overwhelmed by the process.  We will have a productive first meeting even if you are not finished collecting information.  However, it is very helpful to have all the relevant information and items available to us from the beginning, as it will allow us to start the process sooner.  Please feel free to call our office if you have any questions.

Step 1.) Fill out the form below (Click here for the printable version that can be filled out and mailed in).

Step 2.) After completing the form, call our office to schedule an appointment with an attorney for the first consultation.

If needed, there is an overflow box at the end of the form to include additional information.

*Indicates a Required Field

1.

2.

All relatives who would share in your property if you had no Will (e.g. children, parents or siblings):

3.

4.


YesNo

5.


YesNo

YesNo

YesNo

YesNo

6.

7.

List all life insurance policies:

1.

2.

3.

8.

List bank accounts, CDs and money market funds (individual and joint):

Account 1

Account 2

Account 3

Account 4

9.

List all real estate (individual and joint):

Real Estate 1

Real Estate 2

Real Estate 3

10.

List all retirement plans, IRAs, 401-Ks, etc.:

11.

Stocks, bonds, mutual funds and annuities (individual and joint):

1.

2.

3.

12.

List any other property you own or in which you have an interest, including business interests, notes or
mortgages owed to you, autos, boats, valuable jewelry, art work, etc.

13.

14.

15.

16.


YesNo

17.

18.


YesNo

Overflow Box