Aged Care Data Collection

Aged Care Data Collection Form

Full Name*
Address*
Email*
Aged Care Resident's Name and Age*
Status
- Single
- Couple
Family Home
- Homeowner? - Yes
- Homeowner? - No
Value of Home $
Will someone be remaining in the home?
- Yes
- No
- Unsure
Could the home be rented out?
- Yes
- Yes, but needs work
- No
Estimated Rental Income?
If home needs work - estimated costs?
Centrelink Benefits (please choose)
- Age Pension
- DVA Pension
- Disability Pension
Pension Amount paid per fortnight $ (including supplements and disability amount)
Aged Care Required
- High Care
- Low Care
- Unsure
Does the potential resident have a Will?
- Yes
- No
- Unsure
Does the potential resident have Power of Attorney?
- Yes
- No
- Unsure
Does the potential resident have Enduring Guardianship in place?
- Yes
- No
- Unsure

Potential Aged Care Facility if known

Name of Aged Care Facility ..................................................	Advertised Refundable Accommodation Deposit (RAD) $	Daily Extra Service Fee (if any) $ ...........................................

ASSETS - Current Financial Situation of the resident whom will require aged care
Super $ Shares $ Property $ Home Contents $ Motor Vehicle $ Other $
LIABILITIES- Current Financial Situation of the resident whom will require aged care
Home Loan $ Credit Cards $ Reverse Mortgage $ Pension Loan Scheme $ Family Home $
Other Income - for example, superannuation pension, foreign income, annuity, other regular payments
Income Type .................................. Amount per annum $ ........................ Centrelink deductible amount if known $
Other considerations/Questions?

Customised Financial Planning is a friendly and professional financial planning practice. We pride ourselves on the solutions we provide to our clients, on our long-term relationships with clients, and on the qualities of our staff.

The principal of Customised Financial Planning - Stephen Mason, is a Certified Financial Planner and has been providing strategic advice to clients for more than three decades.

We prepare and implement plans for people at various stages in their lives, and for people from all walks of life.

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Aged Care Data Collection

Aged Care Data Collection Form

Retirement

Insurance

Finance

Aged Care Planning

Super $	Shares $	Property $	Home Contents $	Motor Vehicle $	Other $

Home Loan $	Credit Cards $	Reverse Mortgage $	Pension Loan Scheme $	Family Home $

Income Type ..................................	Amount per annum $ ........................	Centrelink deductible amount if known $