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Division of Assets Form

Division of Assets Form

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DATE Spouse Entered Nursing Home: ____________________

             NAME
SOCIAL SECURITY NUMBER
Wife    
Husband    


Listing of Assets (as of date spouse entered nursing home):

  1. Do you have any checking accounts? If so, list the following for each:

    Owner Name
    Bank Name
    Account Number
    Current Balance
           
           
           
           
           


  2. Do you have any KEOGH, IRA, or 401K (retirement accounts). If so, list the following for each account:
    Owner Name
    Type
    Account Number
    Value
           
           
           
           
           
           


  3. Do you have any Savings Accounts? If so, list the following for each account:

    Owner Name
    Bank Name
    Account Number
    Current Balance
           
           
           
           
           
           


  4. Do you have any Certificate(s) of Deposit (CDs)? If so, list the following for each:

    Owner Name
    Bank Name
    Account Number
    Amount
    Date of Maturation
             
             
             
             
             
             


  5. Do you have any stocks? If so, list the following:

    Owner Name
    Company
    Number of Shares
    Price per Share
           
           
           
           
           
           
           


  6. Do you have any Bonds? If so, list the following:

    Owner Name
    Issuer
    Date Purchased
    Purchase Price
    Maturity Value
             
             
             
             
             
             


  7. Do you have any other investments not included above? If so, list the following:

    Owner Name
    Description
    Company
    Account Number
    Value
             
             
             
             
             
             


  8. Do you hold any promissory notes, other collectable unpaid notes or loans owed to you? If so, list separately with amounts:

    Owner Name
    Person Who Owes the Money
    Amount
         
         
         
         
         
         


  9. Do you hold a mortgage? If so, list the value for each:

    Owner Name
    Person who Owes the Money
    Amount
         
         


  10. Do you have a Land Contract? If so, list the following:

    Owner Name
    Legal Description
    Interest Rate
    Encumbrances
           
           


  11. Do you have a Land Lease? If so, list the following:

    Owner Name
    Legal Description
    Value
         
         


  12. Do you have any money set aside for burial such as a Revocable Burial Fund, Irrevocable Burial Trust or Burial Insurance? If so, list the following:

    Owner Name
    Insurance/ Financial Institution
    Account Number
    Value
           
           


  13. Do you have any Trust or Guardianship Funds? If so, list the following:

    Owner Name
    Insurance/Financial Institution
    Account Number
    Value
           
           


  14. Do you own any Life Insurance Policies? If so, list the following for each:

    Owner Name
    Insurance Company and Address
    Insured Person
    Cash Surrender Value
    Face Value
             
             
             
             


  15. Do you own your own home? If so, list the following:

    Owner
    Address
    Value
    Mortgage Balance or Liens
    Major Repairs Needed
             
             


  16. Do you own any additional pieces of property? If so list the following for each:

    Owner Name
    Address
    Value
    Mortgage Balance or Liens
           
           
           
           
           


  17. Do you own a trailer house? If so, list the following for each:

    Owner Name
    Legal Address if Permanent
    Value
         
         


  18. Do you own a motor vehicle? If so, list the following for each:

    Owner Name
    Make
    Model
    Year
           
           


  19. Do you own a motor home? If so, list the following:

    Owner Name
    Make
    Model
    Year
           
           


  20. Do you own a boat? If so, list the following:

    Owner Name
    Make
    Model
    		 Year
           
           


  21. Do you own a life estate in real property? If so list the following:

    Owner Name
    Legal Address
    Value
    Net Income from Life Estate
           
           


  22. Do you own any farm or business equipment? If so, list the following for each:

    Description
    Year Purchased
    Approximate Value
    Used in Business
           
           


  23. Do you own any livestock, poultry or crops? If so, list the following:

    Owner Name
    Description
    Approximate Value
    Used in Trade/Business/
    Own Consumption
           
           
           
           
           
           


  24. Do you have any coin collections, stamp collections, collections of art, etc.? If so, list the following for each collection:

    Owner Name
    Description
    Approximate Value
         
         
         
         
         


  25. Have you purchased a Burial Space? If so, list the following:

    Owner Name
    Location
    Value
         
         


  26. Do you own a Safe Deposit Box? If so, list the contents and value, if any, of each item.

    Contents
    Value
       
       
       
       
       
       
       
       
       
       


  27. Do you have any outstanding debts other than your regular monthly bills? If so, list the following:

    Debtor Name
    Description
    Amount Owed
         
         
         
         
         
         
         
         

 

INCOME

  1. Do you have any income from the following? If so, list the monthly amount received for each owner:

    Husband Wife
    Wages    
    Pensions    
    Social Security    
    Profits from Self Employment    
    Railroad Retirement Benefits    
    Income from Renters/Boarders    
    Income from Interest/Dividends    
    Veterans Pension or Compensation    
         
         
         
         
         
         
         
         
         
    TOTAL    

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