THE COMMUNITY FIRST TRUST COMPANY SUPPLEMENTAL CARE TRUST JOINDER AGREEMENT

Transcription

1 THE COMMUNITY FIRST TRUST COMPANY SUPPLEMENTAL CARE TRUST JOINDER AGREEMENT This is a legal document. You are encouraged to seek independent, professional advice before signing. The undersigned hereby enrolls in and adopts the Declaration of Trust of Community First Trust Company, Supplemental Care Trust dated,, which is incorporated herein by reference. Trust sub-account number: A. GRANTOR INFORMATION Grantor s Name: Grantor s Social Security Number: Telephone: Grantor s Date of Birth: Relationship to Beneficiary: B. BENEFICIARY INFORMATION Beneficiary s Name: Beneficiary s Social Security Number: Telephone: Beneficiary s Date of Birth: Beneficiary s Place of Birth: Hospital: Mother s Name: Father s Name:

2 If the beneficiary has a legal representative (e.g., legal guardian, conservator, representative payee, or agent), what is the name, address, and relationship of such person to the Beneficiary? Name: Relationship to Beneficiary: C. MEDICAL/BENEFIT INFORMATION Does Beneficiary receive Supplemental Security Income? If the Beneficiary receives Medicaid, what is the Medicaid Card Number? List all other forms of government assistance that the Beneficiary receives: If the Beneficiary is covered under any policy of health insurance, please provide: 1. Insurer 2. Policy Number 3. Address/Telephone If the Beneficiary is covered under any prepaid funeral or burial insurance plan, please provide: 1. Insurer 2. Policy Number 3. Address/Telephone 4. Amount of Coverage What is the nature of the Beneficiary s disability? If the Beneficiary s condition has been medically diagnosed, what is the diagnosis?

3 What is the prognosis at this time? Was a Lifecare Plan completed that outlined the kind/type of care required? 1. Name of Planner 2. Address of Planner D. DISTRIBUTION UPON THE BENEFICIARY S DEATH Per Intestate Succession subject to later modification by Last Will and Testament Any trust assets remaining at the Beneficiary s Death that originated from assets of the Beneficiary shall be paid to the or its successor agency (Agency determined by State) as reimbursement to the Medical Assistance Program of the State of for benefits provided by them to the Beneficiary during the (State) Beneficiary s lifetime. In the event that any Trust assets are remaining after payment for reimbursement to the Medical Assistance Program of the State of as set forth above, then the remainder, after reasonable expenses and costs for maintaining the trust, shall be distributed as set forth below: Special Power of Appointment: The Trust Beneficiary, after satisfaction of the distribution provisions described above, shall have a special power of appointment, exercised by his or her will, to appoint the principal and accrued income of this trust to anyone, other than himself or herself, his

4 or her estate, his or her creditors, or the creditors of his or her estate. To the extent that the Beneficiary fails effectively to exercise this special power of appointment, the remaining trust corpus shall be distributed to the Beneficiary s estate. E. USES FOR WHICH SUB-ACCOUNT TRUST DISTRIBUTIONS MAY BE MADE The supplemental needs plan established for the Beneficiary shall be incorporated by reference in this Agreement. This trust sub-account will be administered for the benefit of the Beneficiary. Pending the final preparation of an individualized supplemental needs plan established for the Beneficiary, any non-support items that are required for maintaining a Beneficiary s health, safety and welfare may be provided for the benefit of the Beneficiary when, in the discretion of the Trustee, such requirements are not being provided by any public agency, or are not otherwise being provided by any other source of income available to that Beneficiary. The Grantor recognizes that all distributions are at the Trustee s sole discretion. With this in mind, the Grantor expresses the following desires as to how funds in Trust sub-account might be used: 1. General Supplemental Needs: a. Supplement the care of 2. Specific Supplemental Needs Requested for the Beneficiary: a. Payment of Group Health Insurance Premium, if applicable b. Payment for medical expenses not covered by insurance or Medicaid. c. Payment for improvements to home for accessibility purposes.

5 d. Payment for necessary durable medical or accessibility equipment. 3. Additional supplemental needs, including items of a similar nature to those specified above that are specific to an individualized supplemental needs plan established for the Beneficiary and updated from time to time, may be provided if approved by or his/her designer. F. TRUSTEE FEES Trustee fees will be charged from time to time for the reasonable expenses of the trust, in accordance with the Trust Companies published fee schedule. G. MISCELLANEOUS 1. The provisions of the Joinder Agreement, as entered into as of the date below, may be amended as Grantor and Trustee may jointly agree, so long as any such amendment is consistent with the Declaration of Trust, and then applicable law. 2. Taxes a. Trust sub-account income, whether paid in cash or distributed in other property, may be taxable to the Beneficiary subject to applicable exemptions and deductions. Professional tax advice is recommended. b. Trust sub-account income may be taxable to the Trust, and when this is the case, such taxes shall be payable from the Trust sub-account. 3. If the Grantor intends to enroll more than one Beneficiary under one Trust sub-account, an additional agreement is required between the Grantor and Trustee, regarding such matters as the

6 enrollment fees, annual renewal fees for unfunded enrollments, case management assessment fees, consultation fees, and Trustee administration fees. 4. The Trust administered by Community First Trust Company, Trustee, is a supplemental care trust, governed by the laws of the State of Arkansas, in conformity with the provisions of 42 U.S.C 1396p, amended August 10, 1993, by the Revenue Reconciliation Act of 1993 and other laws. To the extent there is conflict between the terms of this Trust and the governing law as from time to time amended, the law and regulations shall control. IN WITNESS WHEREOF, the undersigned Grantor has reviewed and signed this Joinder Agreement, understands it, and agrees to be bound by its terms, and Trustee has accepted and signed this Joinder Agreement this day of,. Grantor Date Community First Trust Company, Trustee Date Its: