# Asset identifier

# Your plan to fund long-term care expenses

| Date |
| --- |
| Company |
| Address 1 |
| Address 2 |
| Phone number |
| Email address |
| As part of the ongoing financial process，____and I have reviewed and discussed the risks around a life-changing event，such as an extended need for care.The estimated current cost of long-termcare in your area is the following：* |

| • At home care= |  |
| --- | --- |
| • Assisted living= |  |
| • Private nursing home= |  |
| *Source for above costs= |  |

You have informed me that they would like to self-insure against an extended healthcare need using the 
following assets:

| Account name | Account type | Account value | Account number |
| --- | --- | --- | --- |
|  |  |  |  |
|  |  |  |  |
|  |  |  |  |

We will continue to review your plans to self-insure for long-term care expenses and how changes in your life may 
impact your future financial plans.

| Client name: |  |
| --- | --- |
| Client name: | print/sign |
| Client name: |  |
| Client name: | print/sign |
| Advisor name: |  |
| Advisor name: | print/sign |