Law Offices of Charles F Robinson

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  Specializing in Elder Law
Florida Bar Board Certified
410 South Lincoln Avenue | Clearwater, Florida 33756-5826
Phone: 727.441.4516 |  E-mail:
ElderLaw@Charlie-Robinson.com

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Asset Protection Questionnaire 

Our Asset Protection Questionnaire opens in Adobe Acrobat.  Don't have the software on your computer? Click on the Adobe icon below and follow the instructions to download the Adobe Acrobat Reader to your computer.

 

After you open the Questionnaire, click on the Save button and save it to your computer.  Use the Typewriter function to fill it in, save and print.

Asset Protection Questionnaire

Purpose
The purpose of our questionnaire is to gather information relevant to the rules and regulations of the Florida Medicaid Institutional Care Program. Our planning also includes what happens after the death of our client or spouse.

Information gathering process - your job as our client
Fill out the questionnaire as accurately as possible. Charlie's advice depends on a complete understanding of your situation.

  • List all sources of income.
  • List and value all assets.
  • List all gifts in the past 60 months.
  • Provide personal information.
  • Provide information about estate planning.

Education process - Charlie's job
  • Determine assets that the Florida Department of Children and Families (DCF) considers as available assets.
  • Provide strategic information about how to make available assets unavailable within the DCF regulations.
  • Add up available assets.
  • Determine income qualification and, if necessary, explain Qualified Income Trust.
  • Make experienced recommendations about actions necessary to qualify for Medicaid.
  • Review and recommend actions regarding estate planning.

Asset Protection Questionnaire

Frequently asked questions
We realize that our questionnaire looks long and complicated. Not every asset type may apply to you. Only complete the sections that apply to you. If you have a question not addressed below, call our office for help.


How does your questionnaire differ from the financial information questionnaire I filled out for my broker?
Your accountant, your broker, and other financial advisors are concerned with tax issues. Our questionnaire is geared to Medicaid rules which are entirely different from tax laws.

How do I find all the assets?
Current bank or brokerage account statements and your tax returns are a great source of information. Your accountant, your broker, and your financial institutions should also be able to help.

What if I don't know what type of assets are listed on my statement?
Put the balance of your brokerage account statement on the Questionnaire, or put a question mark (?) if you don’t know, or put “no” for none. Do not itemize the individual securities.

Who is the client?
Generally we consider the person who is either in the nursing home or who soon may be there as the client. If both client and spouse are well, we list the husband as the client. The key is to be consistent throughout the questionnaire.


What do you mean by a transfer for less than value?
Any gift or transfer of an asset for which you did not receive equal value in return is a transfer for less than value. List all transfers in the past 60 months so that Charlie can determine how they will affect Medicaid qualification.

Asset Protection Questionnaire

Floridia Board Certied Elder Law Attorney

NAELA

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