Asset Protection Worksheet

Please fill out the asset protection form below. Once you submit the form one of our attorneys will review the information and have an answer to you within 48 hours.
If you have any questions in the meantime, please contact our office at (315) 793-3622. Thank you.

"*" indicates required fields

CONFIDENTIAL – PROTECTED BY ATTORNEY CLIENT PRIVILEGE

General Information

Today's Date*
Name*
Date of Birth*
Spouse Name
(if applicable)
Spouse Date of Birth
(if applicable)
Address*
Are you or your spouse a veteran?*

Current Information

Trust Planning
You*
Spouse*
Type
Date
Long-Term Care Insurance
You*
Spouse*
In A Nursing Home?
You*
Spouse*

Your Health

You - Current Health*
Spouse - Current Health*
Have you given away any assets in the last 60 months?*
Do you have children?*
Does your spouse have children?*

Financial Information

Monthly Income (Pension, Social Security, Etc.)
(If n/a, enter 0)
Assets (Current Value) - You or Joint Name
Current Value
Current Value
Assets (Current Value) - Spouse Name
Assets (Current Value) - Total
Liabilities/Debts - You or Joint
Liabilities/Debts - Spouse
Liabilities/Debts - Total
Monthly Living Expenses - You or Joint
Monthly Living Expenses - Spouse
Monthly Living Expenses - Total
This field is for validation purposes and should be left unchanged.
Asset Protection Worksheet May 17, 2022