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    Name

    Email

    Phone

    Applicant's relationship to you

    Applicant's Age

    Applicant's Martial Status
    SingleMarried

    Applicant's Health Condition
    ExcellentGoodNeeds Support

    Is the Applicant's Gross monthly income exceeding $2,199?
    YesNo

    Is the Applicant's total liquid assets exceeding $119,220 (if married)
    YesNo

    Is the Applicant's total liquid assets exceeding $2,000 (if single)
    YesNo

    Does the Applicant own any investment accounts?
    YesNo

    Does the Applicant own any real estate property?
    YesNo

    Does the Applicant own any vehicles?
    YesNo

    Does the Applicant own any Life Insurance policies?
    YesNo

    Does the Applicant own any Pre-Paid Burial contracts?
    YesNo

    Did any transfers of money or gifting occur in the last five years?
    YesNo

    Questions or Additional Information

    Long Term Care Solutions, LLC

    Clearwater | Sarasota | Odessa

    Phone: 727-240-0750
    Toll Free: 1-844-252-1336
    Email: [email protected]