WisPACT Trust I Contact and Planning Information For. Account Number : ( If Known)

Transcription

1 WisPACT Trust I Contact and Planning Information For Beneficiary: Account Number : ( If Known) The requested information assists the Trustee and WisPACT, Inc. in identifying and contacting individuals associated with the Beneficiary, in identifying and planning for the needs and wants of the Beneficiary, and in updating information over time. Sub-Account Creator: Date this form is executed: SUMMARY OF INFORMATION REQUESTED I. Beneficiary's Prepaid Burial/Funeral Arrangements and Other Trusts II. Beneficiary's Disability III. Beneficiary's Personal Communication Preferences IV. Beneficiary's Public Benefits V. Beneficiary's Doctor and Private Health Insurance VI. Beneficiary's Legal Representatives VII. Updated Contact Information VIII. Updated Advisor Information GENERAL INSTRUCTIONS: Only pages for the information being provided need to be completed and attached to this form. If you need more space, attach an extra page. If information on an individual has been provided under another category or is contained in a document provided with this form, there is no need to repeat information. Examples: If the initial Advisor is the Creator, write "same as creator" in that space; or if a Power of Attorney for Health Care is attached, write "see Power of Attorney for Health Care." Please have the person(s) who has filled this form give his/her info below and sign. This form was completed by: Signature: Print Name: Signature: Print Name:

2 I. Beneficiary's Prepaid Burial/Funeral Arrangements. If the Beneficiary has a burial trust or account, burial insurance or other prepaid burial plan, provide the following information. Please note that a Beneficiary s WisPACT Trust may not be available to cover burial and funeral expenses. Beneficiaries are encouraged to plan accordingly. [ ] Burial Insurance or Life Insurance Funded Burial Contracts. Name of Insurance Company: Address and Telephone: Policy No: Designated Funeral Home: Address of Funeral Home: Phone Number of Funeral Home [ ] Burial/Funeral Trust. Bank and Account Number: Designated Funeral Home: Address of Funeral Home: Phone Number of Funeral Home: [ ] Burial/Funeral Account. Bank and Account Number: Designated Funeral Home: Address of Funeral Home: Phone Number of Funeral Home: All Rights Reserved. Page 2

3 II. Other Trusts. If the WisPACT Beneficiary is a beneficiary of any other trust, provide the following information: Name of Trust Trustee Name Trustee Address Trustee Phone Number III. Nature of Beneficiary s Disability. Check all that apply: CI (Cognitive Impairment) () MH (Mental Health Disability) () DD (Developmental Disability) () SD (Sensory Disability) () PD (Physical Disability) () Other: Specific Diagnoses: Did the Disability begin prior to age 22? () Yes () No Is the Disability expected to be permanent? () Yes () No All Rights Reserved. Page 3

4 IV. Communication Preferences of Beneficiary. a. Gender Identity Preference of Beneficiary: i. Please note that this designation is used to assist WisPACT and the Trustee in addressing the beneficiary properly. () Male () Female b. Direct communication preferences: Please Note: formal correspondence regarding the Trust will still be sent via US Mail, this preference is for trust administration-related communication with WisPACT staff, primarily your Beneficiary Specialist. () The Beneficiary prefers to communicate via Telephone Preferred Phone Number: () The Beneficiary prefers to communicate via Preferred Address: If applicable, please provide specific instructions regarding any communication limitations/preferences that you would like WisPACT s staff to be aware of: All Rights Reserved. Page 4

5 V. Beneficiary's Public Benefits & Income A. Income Benefits. Check boxes and complete information for all income the Beneficiary is receiving. [ ] Supplemental Security Income (SSI / Title XVI). Current Amount of Federal Monthly SSI Benefit: Current Amount of State Monthly SSI Benefit: [ ] Social Security Old Age, Survivor or Disability Insurance Benefits. (Title II) Benefit Paid from Account of: (check all that apply) Type of Benefit: [ ] Disability [ ] Beneficiary [ ] Beneficiary's Parent [ ] Beneficiary's Spouse [ ] Blindness [ ] Retirement [ ] Survivor Current Amount of Total Monthly Benefit: [ ] VA Benefits [ ] Currently Receives VA Disability Compensation Current Amount of Monthly Benefit: Percentage of Disability: [ ] Currently Receives VA Pension Type of Benefit: [ ] Basic Low Income Pension [ ] Aid and Attendance [ ] Housebound Allowance Current Amount of Monthly Benefit(s): All Rights Reserved. Page 5

6 [ ] Beneficiary Receives Income from Working Average Monthly Amount Earned: [ ] Beneficiary Receives Other Income. Average Monthly Amount Received: B. Other Public Benefits Received: 1) FoodShare Wisconsin [ ] Currently Receives FoodShare Wisconsin Benefits Current Amount of Monthly FoodShare Benefit: 2) Housing-Related Assistance [ ] Currently Receives Home Payment/Rental Assistance Benefits (Examples include Section 8, Rent Assistance and their HUD benefits) Type of Housing Benefit Received (be specific): Current Amount of Monthly Housing Benefit: Current Rental Share Obligation (paid by Beneficiary): [ ] Currently Receives WHEAP Home Energy Assistance. All Rights Reserved. Page 6

7 3) Health & Medical Coverage and Benefits Received by Beneficiary. Check all that apply [ ] Medicare [ ] Medical Assistance (Medicaid) Forward Card No. Basis for Medical Assistance Eligibility (if known) [ ] SSI Recipient [ ] Katie Beckett [ ] Disabled Adult Child Status [ ] Autism Waiver [ ] Medically Needy [ ] MAPP Program [ ] Community Integration Program [ ] Brain Waiver [ ] Community Options Program [ ] FamilyCare/ Partnership [ ] Private Insurance [ ] Health Insurance [ ] Medigap or Medicare Supplement [ ] HMO Name of Insurance Company: Group No.: Policy No.: [ ] Long Term Care Insurance Name of Insurance Company: Group No.: Policy No.: 4) MA Long-term Support Services Received by Beneficiary. [ ] COP Benefits Received [ ] Currently on COP Waitlist [ ] FamilyCare / Partnership Services Received Case Manager Name: MCO Name: Telephone Number: All Rights Reserved. Page 7

8 VI. Beneficiary's Legal Representatives. Check the box for each of Beneficiary's Representatives: A. Court-Appointed Representative: Attach Copy of Document Listed Below: [ ] Guardian of the Person Letters of Guardianship [ ] Guardian of the Estate Letters of Guardianship [ ] Standby Guardian of the Person Court Order [ ] Standby Guardian of the Estate Court Order [ ] Conservator Letters of Conservatorship [ ] None Title From Above Name Address Telephone Address Title From Above Name Address Telephone Address All Rights Reserved. Page 8

9 B. Other Representatives [ ] Agent/Power of Attorney for Health Care [ ] Alternate for Health Care [ ] Agent/Power of Attorney for Finances [ ] Alternate for Finances [ ] Parent(s)/Natural Guardian(s) of Minor Beneficiary Title From Above Name Address * If a Power of Attorney or Alternate is checked above, please include a copy of the applicable Power of Attorney Document with your Application Materials. Telephone Address Title From Above Name Address Telephone Address All Rights Reserved. Page 9