Evaluation Department

311 E. Lake St.

Silver Lake, KS 66539

EVALUATION SERVICE AGREEMENT

Sexton & Associates provides the service of analyzing and evaluating a client’s eligibility for the Improved Pension and Aid and

Attendance benefit in providing for long-term care. The Client is desirous of retaining the services of Sexton & Associates, its

assistants or designees or associates as may be necessary, proper or appropriate in its evaluation. These no-cost services are provided

for clients who have been referred by our affiliated financial services professionals or at the discretion of Sexton & Associates.

These services include gathering the information from the client that is necessary to determine eligibility and applying that

information to the regulations that determine eligibility. An attorney that is accredited with the Department of Veterans Affairs and

familiar with Elder Law issues reviews and confirms each portion of the evaluation.

Following the evaluation in which the Client appears to be eligible for the Improved Pension and Aid and Attendance benefit, Sexton

& Associates will explain the Client’s options in a letter to the Client. If, in Sexton & Associates’ opinion, the Client is ineligible but

may become eligible by taking certain steps that are permitted under federal regulations, then Sexton & Associates will make

recommendations as to what the Client needs to do to become eligible in the future. If, however, in Sexton & Associates’ opinion, the

Client is ineligible and there are no certain steps to take to become eligible, then Sexton & Associates will explain the reasons for

ineligibility.

If, however, Sexton & Associates believes that a client is eligible for the Improved Pension and Aid and Attendance benefit, and the

client requests in writing that he or she wants to initiate the process to file a claim for said Improved Pension and Aid and Attendance

benefit, then Sexton & Associates will assist in applying for the Veteran’s Benefit at no cost to the client. The evaluation that Sexton

& Associates provides does not include applying for the benefits on behalf of the client. The application process is a separate,

independent service that is free and is done under the direct supervision of an accredited attorney.

Sexton & Associates is a private company and is not affiliated with the Department of Veterans’ Affairs, Department of Human

Services, or any Federal, State or Local Government agency. Sexton & Associates is not a law firm. Sexton & Associates’ evaluation

of eligibility does not guarantee that a client will be found to be eligible by any Government Agency, including the Department of

Human Services or the Department of Veterans Affairs.

I would like Sexton & Associates to evaluate my eligibility for the Improved Pension and Aid and Attendance benefit that could assist

me in providing for my long-term care.

________________________________________ ________________________________________ ________

Name of Client Signature of Client Date

________________________________________ ________________________________________ ________

Name of Affiliated Financial Services Professional Signature of Affiliated Financial Services Professional Date

Please sign and return this agreement of services along with the completed intake form to the following address.

Sexton & Associates

Attention: Evaluation Department

311 E. Lake St.

Silver Lake, KS 66539

Referral Acknowledgement, Privacy Policy and Client Consent to

Disclosure of Information

__________________________ (printed name of Client, “Client”) acknowledges the referral to Sexton & Associates by,

___________________________(Financial Services Professional, “FSP”) of __________________________ (firm name) for

services related to Sexton & Associates’ services.

Sexton & Associates considers the protection of personal information to be the foundation of customer trust and a sound business

practice. Our firm employs physical, electronic and procedural controls in order to protect Client confidentiality. We will always

restrict access to personal information to those who require it to develop, support and deliver services to you. The only time we will

provide any information about you or your provided information is with your express, written consent as required by law.

Federal law requires this consent form be provided to you (“you” refers to each Client, if more than one). Unless authorized by law,

we cannot disclose, without your consent, your information to third parties for purposes other than the preparation and completion of

your benefits evaluation.

By signing below, you are giving consent for Sexton & Associates to release confidential information to FSP on your behalf. By

signing below, you also acknowledge that if you make an investment or product purchase with FSP, he or she will receive part of any

management fee paid on investments or commission paid on product purchases you make as a result of his or her recommendation.

FSP and Sexton & Associates are separate entities, and Sexton & Associates does not share in commissions or management fees

earned by the FSP. Likewise, FSP does not share in any fees earned by Sexton & Associates.

Sexton & Associates is a private company and is not affiliated with the Department of Veterans’ Affairs, Department of Human

Services, or any Federal, State or Local Government agency. Sexton & Associates is not a law firm. Sexton & Associates’ evaluation

of eligibility does not guarantee that a client will be found to be eligible by any Government Agency, including the Department of

Human Services or the Department of Veterans Affairs.

You are not required to complete this form. If we obtain your signature on this form by conditioning our services on your consent,

your consent will not be valid. If you agree to the disclosure of your information, please sign below.

Printed Name of Client: ____________________________________________________________________________________

Client Signature: ___________________________________________________________________ Date: _________________

Printed Name of Joint Client: ________________________________________________________________________________

Joint Client Signature: _______________________________________________________________ Date: _________________

Sexton & Associates

Attention: Evaluation Department

311 E. Lake St.

Silver Lake, KS 66539

Evaluation Department

311 E. Lake St.

Silver Lake, KS 66539

PLEASE NOTE: IF YOU LIVE IN AN INDEPENDENT LIVING FACILITY, A PHYSICIAN’S STATEMENT MUST ACCOMPANY

THIS INTAKE FORM. AN ELIGIBILITY LETTER WILL NOT BE GENERATED WITHOUT THIS STATEMENT.

Confidential Benefits Evaluation Intake Form

Today’s Date: __________________

How did you hear about us? _________________________

Primary Contact: __________________________

Telephone Number: __________________ Email address: _________________________________________

Relationship to Claimant: __________________ Mailing Address: ____________________________________

Tell us about Recipient (Potential Claimant)

Full name: _______________________________________________________ Age: _______

Phone Number: __________________________ Alternative Phone: _______________________________

Social Security Number: ____________________ Date of birth: __________________

Address: ____________________________________________________________________

City: __________________ State: __________________ Zip code: __________________

How many children do you have? _____ What are their names, ages and place of residence?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Are you currently: Married _____ Divorced ______ Widowed _______ Never Married_______

If you are currently married, do you live with your spouse? Yes_____ No______

(If not, please explain why) ___________________________________________________________________

Spouse's name:_______________________________________________________

Was your spouse a veteran? Yes_______ No ______

Date of marriage: __________________ City/state of marriage: __________________

Spouse’s Social Security number: __________________ Spouse’s date of birth: _______________________

Spouse’s address (if different from client): ______________________________________________________

City: __________________ State: __________________ Zip code: __________________

If you are the widow/widower of a veteran, did you live continuously with the veteran from the date of marriage

until the date of death? Yes______ No_________

(If no, why not?) ___________________________________________________________________________

If you are the widow/widower of a veteran, did you remarry after the veteran passed away? Yes____ No_____

Health Information

In your opinion, would a doctor certify that you need assistance with daily living, such as bathing, dressing,

food preparation, medication management, etc.? Yes _______ No_________

What types of activities do you need assistance with?

__________________________________________________________________________________________

__________________________________________________________________________________________

Facility/Provider Information

Is anyone currently receiving medical/facility care? Veteran ____ Spouse _____ Both ______

Are you currently in a facility? Yes ____ No ______

If yes, which type of facility are you in? Assisted living ____ Nursing home ____ Independent living ____

What is the date that you moved into your first facility?___________________________

What is the name of your facility?___________________________________________

Name of administrator: ___________________________________

What is your monthly cost for this facility? $_______________

Do you currently live at home? Yes_______ No________

Are you receiving at home care? _____ If so, what date did you begin receiving care? ________________

Who provides your at-home care? ______________________________________

Is your at-home care provider compensated for that care? Yes_______ No_________

What is the monthly amount you pay for this care? $_______________

If you are not receiving care, will you soon be receiving care from any of the previous sources?

Yes_____ No_____ If yes, which one? _____________________________________________________

Medical Expense Information

Do you have long-term care insurance? _____ If yes, does it help pay for your current care? _______________

Monthly cost of your LTC? ______________ What amount does it cover? ____________________________

Do you have health insurance? Yes _____ No _______ Monthly cost of that insurance? _________________

What is the name of the health insurance provider? _______________________________

Does your spouse have long-term care insurance? _______

If yes, does it help pay for his/her current care? _________

Monthly cost of spouse LTC? __________________ What amount does it cover? _______________________

Does your spouse have health insurance? Yes _____ No _____ Monthly cost of that insurance ____________

What is the name of the health insurance provider?______________________________

Are you or your spouse currently receiving Medicaid? Self: Yes____ No_____ Spouse: Yes____ No____

What is an estimate of how much you jointly spend on medications monthly? $__________________

Military Service Information

Are you (claimant) a veteran? Yes_____ No ________

Are you (claimant) a widow of a veteran? Yes______ No ______

(If yes, what was your maiden name?) __________________________________________________________

What is the veteran’s place of birth (city and state)? _______________________________________________

In what branch of the military did the veteran serve? ______________________

Did the veteran serve in active duty during a declared state of war? Yes_______ No__________

In which war did the veteran serve? __________

During what years did the veteran serve?__________

Did the veteran receive an honorable discharge? Yes _______ No _______

Have you ever filed a claim with the V.A.? _____ If yes, for what? _________________________________

Are you currently receiving pension benefits or compensation from the VA? Yes_______ No______

If yes, what is the monthly amount you receive? $_____________ What is your VA file number? _________

What is the highest level of education that the veteran completed? ___________________________________

Financial Information

Income:

Please list the GROSS monthly income for both the veteran and spouse (if applicable) and from which source it

is received:

Source Social

Security/

Social

Security

Disability

Pension

(please

specify

source)

Interest/Dividend

Income

Military

Retirement

Pay

SSI or other

Public

Assistance

Other (please

specify

source)

Veteran

Spouse

Assets:

Do you have a trust? Yes ______ No _______

Is it revocable, irrevocable or unknown?_________________

Please list all assets that make up your net worth in the appropriate space below

Account Type Stocks, Bonds,

Mutual Funds

Cash/Non-

Interest

Accounts

Interest-

Bearing

Accounts

IRA’s, 401K’s Annuities

Veteran

Spouse

Do you have a life insurance policy? Yes____ No____ What is the cash value of the policy? ____________

Do you and/or your spouse currently own your primary residence? Yes______ No________

What is the value of this property? $____________ Current Mortgage Amount: ___________________

Do you currently have a reverse mortgage on this property? Yes ______ No _______

Do you currently own any other property or real estate? Yes ______ No _____ If yes, please describe the

property type and the value. _________________________________________________________________

Do you plan on selling either the primary residence or other real estate in the near future? Yes _____ No_____

Previous Marital Information

How many times have you been previously married? _____

How many times was your spouse previously married? _____

Do you have any dependant or disabled children living with you? _____ If yes, how many? _____

How are they dependent on you?______________________________________

Please provide all marital history below, including the city and state of all marriages, date married, how and

why the marriage or marriages ended (divorce or death), and the location of death or divorce.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

I certify that the information provided is true and correct to the best of my knowledge.

Your signature (or POA): ___________________________________ Date signed:__________

Spouse's signature (or POA): ______________________________ Date signed:____________

Once completed to the best of your ability, please mail or fax this form along with Evaluation Service

Agreement and Privacy Policy to the following address:

Sexton & Associates

Attention: Evaluation Department

311 E. Lake St.

Silver Lake, KS 66539

Submitted Date: ________________________

Requested Return Date from Sexton & Associates: _____________________

Sexton & Associates is a private company and is not affiliated with the Department of Veterans’ Affairs, Department of Human Services, or any Federal,

State or Local Government agency. Sexton and Associates is not a law firm. Sexton & Associates’ evaluation of eligibility does not guarantee that a client will

be found to be eligible by any Government Agency, including the Department of Human Services or the Department of Veterans Affairs.