Step 1 — Estimate Continuing Expenses

Household Expenses

Mortgage / Rent

Second Mortgage / Home Equity Loan

Homeowners / Condo Association Dues

Real Estate Taxes (if not included in mortgage payment)

Homeowners / Renters Insurance

Household Supplies

Cleaning / Maid Service

Yard Care / Pest Control

Home Maintenance / Repairs

Utilities

Electricity

Gas / Heating

Water

Sewer

Garbage / Trash

Water Softener / Bottled Water

Telephone - Home and Cellular

#

Cable / Satellite TV

Groceries / Meals

Food - Home

Food - Work

Meals Out

Transportation

Car Loan / Lease Payments

Gasoline

Car Repairs / Maintenance / Oil Changes

Car Wash

Auto Insurance

License / Stickers

Parking / Tolls

Public Transportation / Cabs

#

Insurance Premiums - Other

Life / Accidental Death Insurance

#

Disability Insurance

Health / Medical / Dental / HMO, including Medicare

#

Medicare Supplement Insurance

#

Long-Term Care / Home Health Care

Other

Medical Expenses NOT covered by insurance

Doctors / Dentists / Eye Care

#

Hospitals / Lab Tests

#

Prescriptions and Other Medications

#

Other (including Medical Equipment)

#

Personal Care

Clothing / Shoes

#

Laundry / Dry Cleaning

#

Beauty Shop / Hair Cuts / Hair Care

#

Toiletries / Cosmetics

#

Other

#

Taxes - Other

Income - Federal / State / Local

#

Social Security / Medicare

#

Gifts / Donations

Church / Synagog / Charities

#

Gifts, including Christmas / Hanukkah / Birthdays

#

Other

#

Miscellaneous

Entertainment, except Meals Out

#

Vacations

Cigarettes / Cigars / Other Tobacco

Education

Hobbies / Crafts

#

Legal / Tax Services

#

Membership Dues / Fees

#

Newspapers / Magazines / Books

#

Pet Food / Care

#

Savings / Investments

Other (Postage, fees for Checking Accounts, ATMs, etc.)

#

Total Current Monthly Expenses

Total Continuing Monthly Expenses

#

Step 2 — Calculate Total Available for Assisted Living

Total Current Monthly INCOME

PLUS Monthly Benefits from Long-Term Care Insurance

MINUS Continuing Monthly Expenses

#

Total Amount Available for Assisted Living

Step 3 — Add Income from Assets converted into Income

Converted Asset #1: ______________________________

Converted Asset #2: ______________________________

Converted Asset #3: ______________________________

Converted Asset #4: ______________________________

REVISED Amount Available for Assisted Living

#

These expenses are most likely to continue after moving into an assisted living facility, but may be somewhat lower than current amounts. This is also true for federal income taxes. Most assisted living facilities provide some medical services for their residents. As a result, a portion of the fees paid for assisted living may qualify as a tax-deductible medical expense even if a resident is not living there primarily for medical reasons.