Download - Fillable Intake & 21.2680
Evaluation Department
311 E. Lake St.
Silver Lake, KS 66539
EVALUATION SERVICE AGREEMENT
Sexton & Associates provides the service of analyzing and evaluating a client’s eligibility for the Improved Pension and Aid and
Attendance benefit in providing for long-term care. The Client is desirous of retaining the services of Sexton & Associates, its
assistants or designees or associates as may be necessary, proper or appropriate in its evaluation. These no-cost services are provided
for clients who have been referred by our affiliated financial services professionals or at the discretion of Sexton & Associates.
These services include gathering the information from the client that is necessary to determine eligibility and applying that
information to the regulations that determine eligibility. An attorney that is accredited with the Department of Veterans Affairs and
familiar with Elder Law issues reviews and confirms each portion of the evaluation.
Following the evaluation in which the Client appears to be eligible for the Improved Pension and Aid and Attendance benefit, Sexton
& Associates will explain the Client’s options in a letter to the Client. If, in Sexton & Associates’ opinion, the Client is ineligible but
may become eligible by taking certain steps that are permitted under federal regulations, then Sexton & Associates will make
recommendations as to what the Client needs to do to become eligible in the future. If, however, in Sexton & Associates’ opinion, the
Client is ineligible and there are no certain steps to take to become eligible, then Sexton & Associates will explain the reasons for
ineligibility.
If, however, Sexton & Associates believes that a client is eligible for the Improved Pension and Aid and Attendance benefit, and the
client requests in writing that he or she wants to initiate the process to file a claim for said Improved Pension and Aid and Attendance
benefit, then Sexton & Associates will assist in applying for the Veteran’s Benefit at no cost to the client. The evaluation that Sexton
& Associates provides does not include applying for the benefits on behalf of the client. The application process is a separate,
independent service that is free and is done under the direct supervision of an accredited attorney.
Sexton & Associates is a private company and is not affiliated with the Department of Veterans’ Affairs, Department of Human
Services, or any Federal, State or Local Government agency. Sexton & Associates is not a law firm. Sexton & Associates’ evaluation
of eligibility does not guarantee that a client will be found to be eligible by any Government Agency, including the Department of
Human Services or the Department of Veterans Affairs.
I would like Sexton & Associates to evaluate my eligibility for the Improved Pension and Aid and Attendance benefit that could assist
me in providing for my long-term care.
________________________________________ ________________________________________ ________
Name of Client Signature of Client Date
________________________________________ ________________________________________ ________
Name of Affiliated Financial Services Professional Signature of Affiliated Financial Services Professional Date
Please sign and return this agreement of services along with the completed intake form to the following address.
Sexton & Associates
Attention: Evaluation Department
311 E. Lake St.
Silver Lake, KS 66539
Referral Acknowledgement, Privacy Policy and Client Consent to
Disclosure of Information
__________________________ (printed name of Client, “Client”) acknowledges the referral to Sexton & Associates by,
___________________________(Financial Services Professional, “FSP”) of __________________________ (firm name) for
services related to Sexton & Associates’ services.
Sexton & Associates considers the protection of personal information to be the foundation of customer trust and a sound business
practice. Our firm employs physical, electronic and procedural controls in order to protect Client confidentiality. We will always
restrict access to personal information to those who require it to develop, support and deliver services to you. The only time we will
provide any information about you or your provided information is with your express, written consent as required by law.
Federal law requires this consent form be provided to you (“you” refers to each Client, if more than one). Unless authorized by law,
we cannot disclose, without your consent, your information to third parties for purposes other than the preparation and completion of
your benefits evaluation.
By signing below, you are giving consent for Sexton & Associates to release confidential information to FSP on your behalf. By
signing below, you also acknowledge that if you make an investment or product purchase with FSP, he or she will receive part of any
management fee paid on investments or commission paid on product purchases you make as a result of his or her recommendation.
FSP and Sexton & Associates are separate entities, and Sexton & Associates does not share in commissions or management fees
earned by the FSP. Likewise, FSP does not share in any fees earned by Sexton & Associates.
Sexton & Associates is a private company and is not affiliated with the Department of Veterans’ Affairs, Department of Human
Services, or any Federal, State or Local Government agency. Sexton & Associates is not a law firm. Sexton & Associates’ evaluation
of eligibility does not guarantee that a client will be found to be eligible by any Government Agency, including the Department of
Human Services or the Department of Veterans Affairs.
You are not required to complete this form. If we obtain your signature on this form by conditioning our services on your consent,
your consent will not be valid. If you agree to the disclosure of your information, please sign below.
Printed Name of Client: ____________________________________________________________________________________
Client Signature: ___________________________________________________________________ Date: _________________
Printed Name of Joint Client: ________________________________________________________________________________
Joint Client Signature: _______________________________________________________________ Date: _________________
Sexton & Associates
Attention: Evaluation Department
311 E. Lake St.
Silver Lake, KS 66539
Evaluation Department
311 E. Lake St.
Silver Lake, KS 66539
PLEASE NOTE: IF YOU LIVE IN AN INDEPENDENT LIVING FACILITY, A PHYSICIAN’S STATEMENT MUST ACCOMPANY
THIS INTAKE FORM. AN ELIGIBILITY LETTER WILL NOT BE GENERATED WITHOUT THIS STATEMENT.
Confidential Benefits Evaluation Intake Form
Today’s Date: __________________
How did you hear about us? _________________________
Primary Contact: __________________________
Telephone Number: __________________ Email address: _________________________________________
Relationship to Claimant: __________________ Mailing Address: ____________________________________
Tell us about Recipient (Potential Claimant)
Full name: _______________________________________________________ Age: _______
Phone Number: __________________________ Alternative Phone: _______________________________
Social Security Number: ____________________ Date of birth: __________________
Address: ____________________________________________________________________
City: __________________ State: __________________ Zip code: __________________
How many children do you have? _____ What are their names, ages and place of residence?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you currently: Married _____ Divorced ______ Widowed _______ Never Married_______
If you are currently married, do you live with your spouse? Yes_____ No______
(If not, please explain why) ___________________________________________________________________
Spouse's name:_______________________________________________________
Was your spouse a veteran? Yes_______ No ______
Date of marriage: __________________ City/state of marriage: __________________
Spouse’s Social Security number: __________________ Spouse’s date of birth: _______________________
Spouse’s address (if different from client): ______________________________________________________
City: __________________ State: __________________ Zip code: __________________
If you are the widow/widower of a veteran, did you live continuously with the veteran from the date of marriage
until the date of death? Yes______ No_________
(If no, why not?) ___________________________________________________________________________
If you are the widow/widower of a veteran, did you remarry after the veteran passed away? Yes____ No_____
Health Information
In your opinion, would a doctor certify that you need assistance with daily living, such as bathing, dressing,
food preparation, medication management, etc.? Yes _______ No_________
What types of activities do you need assistance with?
__________________________________________________________________________________________
__________________________________________________________________________________________
Facility/Provider Information
Is anyone currently receiving medical/facility care? Veteran ____ Spouse _____ Both ______
Are you currently in a facility? Yes ____ No ______
If yes, which type of facility are you in? Assisted living ____ Nursing home ____ Independent living ____
What is the date that you moved into your first facility?___________________________
What is the name of your facility?___________________________________________
Name of administrator: ___________________________________
What is your monthly cost for this facility? $_______________
Do you currently live at home? Yes_______ No________
Are you receiving at home care? _____ If so, what date did you begin receiving care? ________________
Who provides your at-home care? ______________________________________
Is your at-home care provider compensated for that care? Yes_______ No_________
What is the monthly amount you pay for this care? $_______________
If you are not receiving care, will you soon be receiving care from any of the previous sources?
Yes_____ No_____ If yes, which one? _____________________________________________________
Medical Expense Information
Do you have long-term care insurance? _____ If yes, does it help pay for your current care? _______________
Monthly cost of your LTC? ______________ What amount does it cover? ____________________________
Do you have health insurance? Yes _____ No _______ Monthly cost of that insurance? _________________
What is the name of the health insurance provider? _______________________________
Does your spouse have long-term care insurance? _______
If yes, does it help pay for his/her current care? _________
Monthly cost of spouse LTC? __________________ What amount does it cover? _______________________
Does your spouse have health insurance? Yes _____ No _____ Monthly cost of that insurance ____________
What is the name of the health insurance provider?______________________________
Are you or your spouse currently receiving Medicaid? Self: Yes____ No_____ Spouse: Yes____ No____
What is an estimate of how much you jointly spend on medications monthly? $__________________
Military Service Information
Are you (claimant) a veteran? Yes_____ No ________
Are you (claimant) a widow of a veteran? Yes______ No ______
(If yes, what was your maiden name?) __________________________________________________________
What is the veteran’s place of birth (city and state)? _______________________________________________
In what branch of the military did the veteran serve? ______________________
Did the veteran serve in active duty during a declared state of war? Yes_______ No__________
In which war did the veteran serve? __________
During what years did the veteran serve?__________
Did the veteran receive an honorable discharge? Yes _______ No _______
Have you ever filed a claim with the V.A.? _____ If yes, for what? _________________________________
Are you currently receiving pension benefits or compensation from the VA? Yes_______ No______
If yes, what is the monthly amount you receive? $_____________ What is your VA file number? _________
What is the highest level of education that the veteran completed? ___________________________________
Financial Information
Income:
Please list the GROSS monthly income for both the veteran and spouse (if applicable) and from which source it
is received:
Source Social
Security/
Social
Security
Disability
Pension
(please
specify
source)
Interest/Dividend
Income
Military
Retirement
Pay
SSI or other
Public
Assistance
Other (please
specify
source)
Veteran
Spouse
Assets:
Do you have a trust? Yes ______ No _______
Is it revocable, irrevocable or unknown?_________________
Please list all assets that make up your net worth in the appropriate space below
Account Type Stocks, Bonds,
Mutual Funds
Cash/Non-
Interest
Accounts
Interest-
Bearing
Accounts
IRA’s, 401K’s Annuities
Veteran
Spouse
Do you have a life insurance policy? Yes____ No____ What is the cash value of the policy? ____________
Do you and/or your spouse currently own your primary residence? Yes______ No________
What is the value of this property? $____________ Current Mortgage Amount: ___________________
Do you currently have a reverse mortgage on this property? Yes ______ No _______
Do you currently own any other property or real estate? Yes ______ No _____ If yes, please describe the
property type and the value. _________________________________________________________________
Do you plan on selling either the primary residence or other real estate in the near future? Yes _____ No_____
Previous Marital Information
How many times have you been previously married? _____
How many times was your spouse previously married? _____
Do you have any dependant or disabled children living with you? _____ If yes, how many? _____
How are they dependent on you?______________________________________
Please provide all marital history below, including the city and state of all marriages, date married, how and
why the marriage or marriages ended (divorce or death), and the location of death or divorce.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I certify that the information provided is true and correct to the best of my knowledge.
Your signature (or POA): ___________________________________ Date signed:__________
Spouse's signature (or POA): ______________________________ Date signed:____________
Once completed to the best of your ability, please mail or fax this form along with Evaluation Service
Agreement and Privacy Policy to the following address:
Sexton & Associates
Attention: Evaluation Department
311 E. Lake St.
Silver Lake, KS 66539
Submitted Date: ________________________
Requested Return Date from Sexton & Associates: _____________________
Sexton & Associates is a private company and is not affiliated with the Department of Veterans’ Affairs, Department of Human Services, or any Federal,
State or Local Government agency. Sexton and Associates is not a law firm. Sexton & Associates’ evaluation of eligibility does not guarantee that a client will
be found to be eligible by any Government Agency, including the Department of Human Services or the Department of Veterans Affairs.