Note: As more fully described in the Disclaimer and Agreement which govern your use and limit the web site owner's liability of this web site:

• No attorney client relationship is solicited, intended, or established by the creation, publication, downloading, observation, perception, use, or any other communication through this site.
• Observation or perception of the materials posted on this web site does not establish any form of attorney-client relationship with the web site owner or any other entity.
• This data collection form is provided as a convenience for general observers of this web site and as an aid to established clients of the web site owner.
• Confidential information is not solicited and should never be transmitted to the web site owner, or to any person affiliated with the web site owner, until and unless an attorney client relationship is established by a written legal services agreement signed by the web site owner and by the observer of the web site.
• The web site owner accepts no responsibility for the transmission of any confidential information, or any obligation as to such information which may received, in the absence of a written legal services agreement signed by the web site owner and the observer.

T&M Staff : ____________
Lawyer: _______

T&M Client Agreement date: ______
Date completed form received: _____________

PERSON COMPLETING THIS FORM: _____________________

RELATION TO DISABLED PERSON (Self, parent, guardian, etc.):_______________

ADDRESS: _______________________________________

                    _______________________________________

TELEPHONE # _______________ (work)  # _______________ (home)
                        # _______________ (pager) # _______________ (fax)
 

NAME:  ___________________________________________________

Gender of Disabled Person:     Lady: _______    Gentleman: ______
 

RESIDENCE ADDRESS: ___________________________________________________

MAILING ADDRESS CITY / STATE ZIP:
            ___________________________________________________

            ___________________________________________________

TELEPHONE NUMBER: Area Code:  _____  - _____________

 DOB: ______________AGE: ______ SSN: ______________MARITAL STATUS:________

 PRESENT LOCATION (PATIENT/ROOM #): __________________________________
 

RESIDENCE IN VIRGINIA COUNTY  /  CITY:   ________________________

DATE OF DISABILITY (OR BIRTH, IF SINCE BIRTH): _________________________

DATE OF SOCIAL SECURITY / STATE DISABILITY
OFFICE DETERMINATION OF DISABILITY:  _________________________
 

    This is the person who will be primarily responsible for the assets in the trust. There is usually a second person or bank or trust company to serve if this person is not able to serve.

NAME :_______________________________________________

 RESIDENCE ADDRESS:___________________________________________________

COUNTY/CITY/ZIP:___________________________ TELEPHONE: _____________

 DOB:______________AGE:______SSN:______________RELATION:__________________

NOTE: The Trustee should not be a person with financial troubles and cannot be a person with a history of felony or larceny. In most cases the Trustee will be required to disclose his or her history of bankruptcy and felony convictions.

    This is the person who will be responsible for trust assets when the primary trustee is not available to serve.

NAME :_______________________________________________

 RESIDENCE ADDRESS:___________________________________________________

COUNTY/CITY/ZIP:___________________________ TELEPHONE: _____________

 DOB:______________AGE:______SSN:______________RELATION:__________________

NOTE: The Trustee should not be a person with financial troubles and cannot be a person with a history of felony or larceny. In most cases the Trustee will be required to disclose his or her history of bankruptcy and felony convictions.

CURRENT AGENT UNDER POWER OF ATTORNEY OR ADVANCE MEDICAL DIRECTIVE; CURRENT GUARDIAN AND / OR CONSERVATOR, IF ANY:

NAME :_______________________________________________

 RESIDENCE ADDRESS:___________________________________________________

COUNTY/CITY/ZIP:___________________________ TELEPHONE: _____________

RELATION: _________ Agent _________ Guardian _________ Conservator

RELATION TO DISABLED PERSON: ___________ (e.g., father, mother, friend)

TELEPHONE NUMBER:__________ / :__________ /:__________

DATE OF POWER OF ATTORNEY or ORDER: _____________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 Social Security $_________/mo type:__________________________________

 Retirement $_________/mo source:________________________________

 Interest  $_________/mo source:________________________________

 Other  $_________/mo source:________________________________

Real Estate
  Location:______________________________________insured?____________

  Tax Assessed value $__________________ Taxes due?__________________

(REAL ESTATE INFORMATION CONTINUED)
   How held?_________________________________________ (sole, t/e, etc.)

  Mortgage?___________________________________________________________

Motor vehicles
  Make/Model______________Year__________Value $_________

  Make/Model______________Year__________Value $_________

Other valuable personal property:

 Describe:__________________________________Value $_________

 Bank Accounts:

 Location:___________________ Acct # ______________ Value $_________

 Location:___________________ Acct # ______________ Value $_________

 Location:___________________ Acct # ______________ Value $_________

KIND            OWNER            BENEFICIARY         FACE  AMT     CASH AMT  LOAN?
whole/
term
___________ ______________ ______________ ______________  ________  _________

___________ ______________ ______________ ______________  ________ _________

___________ ______________ ______________ ______________  ________ _________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________.

Attending Physician:_____________________________ Date last visit:_____________

 Address/Phone / Fax / Pager / E-Mail: _________________________________

_________________________________________________________________________

Psychiatrist:____________________________________ Date last visit:_______

 Address/Phone / Fax / Pager / E-Mail: _________________________________

_________________________________________________________________________

Hospital & Date of Admission:____________________ Phone:_________________

Social Worker:___________________________________ Phone/Pager:_________________

Nursing/Adult Home:______________________________ Phone/Pager:_________________

 Address:____________________________________ Contact:_______________

Medicare A____ B____ Claim # _______________

 Medicare Supplement_________________________ Claim # _______________

 Medicaid Claim # ___________________________ City/County____________

  Eligibility Date ______________________ Worker:________________
 

    If the fund which will be placed in the Trust is from a personal injury claim of the Disabled Person, please state the date of the injuries, describe the personal injuries, and give the name and address of the personal injury attorneys representing the Disabled Person.  If there are pleadings in the case already, please provide them to Thompson & McMullan, P.C.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Note: As more fully described in the Disclaimer and Agreement which govern your use and limit the web site owner's liability of  this web site:

1. No attorney client relationship is solicited, intended, or established by the creation, publication, downloading, observation, perception, use, or any other communication through this site.
2. Observation or perception of the materials posted on this web site does not establish any form of attorney-client relationship with the web site owner or any other entity.
3. This data collection form is provided as a convenience for general observers of this web site and as an aid to established clients of the web site owner.
4. Confidential information is not solicited and should never be transmitted to the web site owner, or to any person affiliated with the web site owner, until and unless an attorney client relationship is established by a written legal services agreement signed by the web site owner and by the observer of the web site.
5. The web site owner accepts no responsibility for the transmission of any confidential information, or any obligation as to such information which may received, in the absence of a written legal services agreement signed by the web site owner and the observer.

 

 
 
 

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