Date________________ Home Phone No._____________________ Business Phone No. ___________________This form is extremely important.  Your accuracy and completeness in responding will help me best represent you.Bring this information with you to the appointment. A. PERSONAL DATAFull Name___________________________________________________________________________________     (print name as shown on your checks)Street Address ________________________________________________________________________________City__________________________________________________________ State___________ Zip____________Birth Date_____________________________________	Social Security No.____________________________U.S. Citizen?     Yes ___	No ___				Veteran?     Yes ___         No ___	If widowed, please list date of death of spouse______________________________________________________Was your former spouse a Veteran?        Yes ___	No ___B. MEDICAL DATA1.	HEALTHDiagnosis ___________________________________________________________________________________Prognosis____________________________________________________________________________________Course of Treatment___________________________________________________________________________If you are already in a nursing home, please indicate the name of the nursing home and the date first entered______________________________________________________________________________________2.	PHYSICIANFull Name of Primary Physician _________________________________________________________________Street Address________________________________________________________________________________City_________________________________________________________ State__________ Zip______________ 3.	STATE PHARMACEUTICAL PLANAre you currently on PAAD (Pharmaceutical Assistance to the Aged and Disabled Program) or any other state pharmaceutical plan? 	Yes ___		No ___C. MONTHLY INCOMESocial Security Benefits 				$___________________(include $43.80 Medicare Part B Deduction, if applicable)Retirement Benefits (Gross)				$___________________Veterans Disability Income				$___________________Annuity Income					$___________________Rental Income					$___________________TOTAL MONTHLY INCOME			$___________________If there is a pension, please list the gross pension amount, including any monies taken out for federal income taxes, health insurance, or any other reason.Could this pension amount increase in the future?	Yes ___ 	No ___Do not include interest and dividend income on this form.D. MONTHLY COST OF NURSING HOMEMonthly Nursing Home Cost 			$___________________Monthly Prescription Cost 				$___________________Monthly Incontinent Cost 				$___________________Monthly Other Cost 					$___________________Total Monthly Cost					$___________________The nursing home is paid through _________________________________________________(month/year).E. ASSETS/LIABILITIESPlease insert the value of each asset/liability in the appropriate space. ASSET/LIABILITY	ASSET TOTAL	LIA-BIL-I-TY TOTAL PERSONAL EFFECTS 		CHECKING ACCOUNT		SAVINGS ACCOUNT		MONEY MARKET ACCOUNT		CERTIFICATES OF DEPOSIT		RESIDENCE (ASSESSED VAL-UE)BLOCK#___________  LOT#___________ (Ob-tain from Tax Bill)		OTHER REAL ESTATE		AUTOMOBILE(S)		MUTUAL FUNDS		STOCKS		BONDS		ANNUITIES		CASH VALUE - LIFE INSURANCE		IRA		NURSING HOME DEPOSIT	 	OTHER		OTHER		TOTAL		What did you pay for your current home including any improvements? $_____________________________Address of any real property other than personal residence:                   (1)Street ________________________________________City ______________State________Zip___________Tax Block #                           , Lot #                            (Can be obtained from Tax Bill)What did you pay for this property including any improvements? $_____________________________________ (2)Street ________________________________________City ______________State________Zip___________Tax Block #                           , Lot #                            (Can be obtained from Tax Bill)What did you pay for this property including any improvements? $_____________________________________Name of Homeowner's Insurance Company________________________________________________________Street Address________________________________________________________________________________City_________________________________________________________ State__________ Zip______________Phone No.___________________________________	Policy No._________________________________F. GIFTSPlease list gifts made in excess of $3,000 in any one month, to an individual or group of individuals, within the past 36 months:Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________Recipient___________________________________	Date ______________	Amount ____________ G.	LIFE INSURANCECOMPANY NAME(include address and policy #)	TYPE	DEATHBENEFITVALUE		FACE VALUE 	CASH VALUE		INSURED	       OWNER	BENEFICIARY(Include the cash value of the life insurance on the life insurance line in Section E)It is very important to know the cash value and the death benefit of your life insurance policy.  To obtain the cash value of the policy, please call your insurance agent, or call the insurance company directly.H. CHILDREN (if applicable)

	Are all of your children in good health?				Yes ___	No ___Are any of your children blind?					Yes ___	No ___Are any of your children disabled? 					Yes ___	No ___Are any of your children receiving SSI or other form of government entitlement?  						Yes ___	No ___Do any of your family members have any problems with:	Aids?				Yes ___	No ___Drug Addiction?			Yes ___	No ___Alcoholism?			Yes ___	No ___Spendthrift?			Yes ___	No ___Do any of your children live with you in your home?		Yes ___	No ___If yes, name of child________________________________________________________________________Does a sibling live in your home with you?			Yes ___	No ___If yes, name of sibling_______________________________________________________________________I. MISCELLANEOUSDo you have any other legal issues which I should be aware of:	Yes ___	No ___If yes, please explain _____________________________________________________________________________________________________________________________________________________________________J. REFERRALBy Whom Were You Referred To This Office?Name _______________________________________________________________________________________Street Address________________________________________________________________________________City_________________________________________________________ State__________ Zip______________K. CERTIFICATIONResena de hotel SandnesThe undersigned hereby represents to Roy W. Wilkes, Esquire The Elder & Disability Law Firm., and each of its attorneys that theinformation contained in this intake form is accurate and complete, and that the undersigned understandsthat the law firm and its individual lawyers will rely on this information.  I understand that if the informationcontained herein is inaccurate or incomplete, the recommendations made by the law firm may not beappropriate.Signature of Client or Client Representative:____________________________________________________