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Want to learn more?
	Phone: 512.441.2825
	gbeasley@nextfinancial.com

How to Prequalify?

Do you qualify for the Improved Pension Benefit and/or one of the two add-ons, “Housebound” or “Aid and Attendance”?

To prequalify, please fill out the form below and then click the submit button. Please indicate if you are currently working with one of our analysts. All information provided is confidential and will not be used for any other purpose.

We receive many inquiries every day, and therefore, may take us a few days to respond to your form. You may also call 512.441.2825 to leave a message or e-mail gbeasley@nextfinancial.com

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INQUIRER INFORMATION:

* First Name:			* Last Name:
Address:
City:			* Contact Phone Number:
State/Region:	Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands of the U.S. Virginia Washington West Virginia Wisconsin Wyoming		* E-mail:
Zip:			* E-mail Confirmation:
For whom are you requesting this information?		Other Self Mother Father Aunt Uncle Other? Please specify:
Are you currently living in a nursing home or assisted living center?    Yes No
How were you referred to us, or list the facility where you are currently located?
TELL US ABOUT THIS PERSON:
First Name:		Age:                            Marital Status: Single Divorced Married Widowed
Last Name:		Spouse's Name:		Age:
Current Address:
City/State/Zip:        Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands of the U.S. Virginia Washington West Virginia Wisconsin Wyoming
Current Resident Type: Home Apartment Hospital Adult Community Assisted Living Nursing Home        Do you own or rent:   Own Rent
Monthly Payment:		Property Value:
Do you plan on living in assisted living soon? Yes No
If so, what do you plan on spending per month?

WARTIME SERVICE QUESTIONNAIRE:
VETERAN					SURVIVING SPOUSE OF A VETERAN
Is the veteran age 65 or older or permanently disabled?			Yes No		Is the un-remarried surviving spouse the last spouse of the veteran at the time of his death?			Yes No
Did theveteran serve at least 90 days in active service, with at least one day during a wartime period?			Yes No		Did the deceased veteran serve at least 90 days in active service, with at least one day during a wartime period?			Yes No
Did the veteran receive an honorable or general discharge?			Yes No		Did the deceased veteran receive an honorable or general discharge?			Yes No

HEALTH QUESTIONNAIRE:

MEDICAL DIAGNOSIS:

Alzheimer's   Dementia   Other

SELECT THE ACTIVITIES OF DAILY LIVING, THIS PERSON REQUIRES ASSISTANCE WITH:

Dressing   Bathing   Toileting   Transferring   Continence   Meals   Medication Mgmt

MONTHLY INCOME/EXPENSE QUESTIONNAIRE:
INCOME	VETERAN	SPOUSE
Social Security	$ *	$ *
Pensions	$ *	$ *
Interest Income	$	$
VA Retirement or Disability	$	$
Other	$	$
Total Monthly Income	$ *	$ *
EXPENSES
Medicare Part-B	$	$
Private Medical Insurance/ Medicare Supp.	$	$
Senior HMO	$	$
Monthly Home Care Costs	$ *	$ *
Monthly Cost of Facility	$	$
Cost of Long Term Care Insurance	$	$
Total Monthly Medical Expenses	$	$
SAVINGS
Checking, Savings, CDs	$	$
Stocks, Bonds, Mutual Funds	$	$
IRAs	$	$
Other	$	$
Total Asset/Savings:	$ *	$ *
Click the submit button to send the form.