T&M Staff : ____________
Lawyer: _______

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

PERSON COMPLETING THIS FORM: _____________________

RELATION TO INCAPACITATED PERSON: _____________________

ADDRESS: _______________________________________

                    _______________________________________

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

NAME:  ___________________________________________________

 COUNTY/CITY/ZIP ________________________ TELEPHONE NUMBER:_____________

 DOB: ______________AGE: ______ SSN: ______________MARITAL STATUS:________

 PRESENT LOCATION (PATIENT/ROOM #): __________________________________

    The guardian makes health care decisions for the incapacitated person.

NAME :_______________________________________________

 RESIDENCE ADDRESS:___________________________________________________

COUNTY/CITY/ZIP:___________________________ TELEPHONE: _____________

 DOB:______________AGE:______SSN:______________RELATION:__________________

    The conservator makes financial decisions for the incapacitated person.

 RESIDENCE ADDRESS:___________________________________________________

COUNTY/CITY/ZIP:___________________________ TELEPHONE: _____________

 DOB:______________AGE:______SSN:______________RELATION:__________________

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 INCAPACITATED: ___________ (e.g., father, mother, friend)

TELEPHONE NUMBER:__________ / :__________ /:__________

DATE OF POWER OF ATTORNEY or ORDER: _____________

Why is another conservator or guardian required?

__________________________________________________________________________

__________________________________________________________________________.

LIST CLOSEST RELATIVES OF PROPOSED INCAPACITATED, IN FOLLOWING ORDER: (spouse, all adult children, parents and all adult siblings or, if no such relatives are known, at least three other known relatives of the respondent, including step-children.):

Name/Age   Relation  Full Address & Phone (work and home, if known)

1.
__________________________________________________________________________

__________________________________________________________________________

2.
__________________________________________________________________________

__________________________________________________________________________

3.
__________________________________________________________________________

__________________________________________________________________________

4.
__________________________________________________________________________

__________________________________________________________________________

5.
__________________________________________________________________________

__________________________________________________________________________

6.
__________________________________________________________________________

__________________________________________________________________________

7.
__________________________________________________________________________

__________________________________________________________________________

8.
__________________________________________________________________________

__________________________________________________________________________

9.
__________________________________________________________________________

__________________________________________________________________________

10.
__________________________________________________________________________

__________________________________________________________________________

 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:________________
 

Please describe any funeral, cremation, or organ donation plan or intentions for the incapacitated person.  Include the name and telephone number of any funeral services director having written instructions, or any person holding a funeral services power of attorney or other authority.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Religious preferences of the incapacitated person: ____________________________________.

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