NYSARC, INC. COMMUNITY TRUST COMMUNITY TRUST I BENEFICIARY PROFILE SHEET AND

NYSARC, INC. COMMUNITY TRUST
(A Trust for Persons with Disabilities)
COMMUNITY TRUST I
BENEFICIARY PROFILE SHEET AND
JOINDER AGREEMENT
NYSARC, Inc. Trust Services
P.O. Box 1531
Latham, NY 12110
Telephone: 518-439-8323
Toll Free: 800-735-8924
Facsimile: 518-439-2670
E-mail: trustdept@nysarc.org
Copyright 1997 © NYSARC, Inc.
Revised May 31, 2013
WELCOME TO NYSARC, INC. TRUST SERVICES
As part of your application process, please be sure you have completed everything on the
checklist below and return this sheet with your Beneficiary Profile Sheet and
Joinder Agreement.
COMMUNITY TRUST I
SUBMISSION CHECKLIST
______
You have read the Information and Procedures pertaining to the trust program and
understand its contents.
______
The Joinder Agreement is complete with no unanswered questions.
______
You have provided the contact information of the individual
knowledgeable in Medicaid law assisting you with your application
(required).
______
The Joinder Agreement is signed by the appropriate individual on both
pages 7 and 12. (If signed by a Guardian or POA, please enclose a copy
of the legal document granting authority.)
______
The Joinder Agreement is notarized on page 12.
______
You have enclosed a copy of your Social Security Card (No substitutes).
______
You have enclosed a copy of your Social Security Award letter, indicating type of
benefit received and claim number.
______
You have enclosed a copy of all applicable court orders, decree or letters of
guardianship.
______
You have enclosed a copy of any existing funeral arrangements.
______
NO requests for disbursements, bills, or invoices are enclosed.
(Any disbursement information enclosed will be returned to sender).
ALLOW 30 DAYS FOR PROCESSING.
INCOMPLETE JOINDER AGREEMENTS WILL BE RETURNED.
__________________________
_________________________
_________
SIGNATURE OF DONOR/GUARDIAN
RELATIONSHIP TO BENEFICIARY
DATE
CTI
Page 1 of 12
Rev. 5/31/13
NOTE: All questions must be answered or your application will be delayed.
Beneficiary Profile Sheet
1.
Name of Donor (Generally same as Beneficiary): ________________________________
(First Name, Middle Name, Last Name)
Social Security No. of Donor: _______________________________________________
Address of Donor: _________________________________________________________
_________________________________________________________
Telephone Number of Donor: ________________________________________________
2.
Name of Disabled Beneficiary (In-Kind Beneficiary): ____________________________
(First Name, Middle Name, Last Name)
Social Security No. of Disabled Beneficiary: ___________________________________
Please return a copy of the Social Security Card with the Profile and Joinder Agreement. If unavailable,
please contact the SSA at 1-800-772-1213 (or 1-800-325-0778 for the deaf or hearing impaired) for
instructions on how to apply for a replacement card.
Address:_________________________________________________________________
_________________________________________________________________
Telephone Number: (Day):____________________ (Evening):___________________
3.
County of Residence: ______________________________________________________
Place of Birth: ___________________________________________________________
Citizenship: _____________________________________________________________
Date of Birth: ________________________ Gender:____________________________
Please list qualifying disabilities: ___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4.
Is the purpose of establishing this trust the result of a Court Order?
Yes___ No___
(If yes, please include a copy of Court Order)
5.
Is the purpose of establishing this account to shelter monthly income? Yes___ No___
Indicate estimated monthly deposit: $______________
(Note: This is supplemental information for NYSARC, Inc. purposes only. This amount may be changed
at any time with no effect on the Joinder Agreement.)
CTI
Page 2 of 12
Rev. 5/31/13
6.
Beneficiary Income:
If you receive any form of Social Security benefit, please submit a copy of your “proof
of income” letter, indicating your claim number. If you do not have this, please visit
the local Social Security Office or call them 1-800-772-1213 (or 1-800-325-0778
for the deaf or hearing impaired) and follow the instructions to obtain a copy.
Does the Beneficiary receive Supplemental Security Income (SSI)?
Yes____ No____
Does the Beneficiary receive Social Security Disability Income (SSDI)? Yes____ No____
Does the Beneficiary receive Social Security Retirement Income (SSA)? Yes____ No____
Does the Beneficiary receive Survivor Benefits? Yes_____ No_____
Does the Beneficiary receive other income? Yes_____ No_____
(If yes, please provide detail)
________________________________________________________________________
________________________________________________________________________
Does the Beneficiary receive Medicaid? Yes ______ No ______ Pending____________
If yes, list Medicaid card number: ____________________________________________
If the Beneficiary receives other benefits or entitlements, such as Food Stamps, HUD
Sec. 8, etc. list these benefits and monthly amounts:
________________________________________________________________________
________________________________________________________________________
7.
(a) Indicate the living arrangement of the Beneficiary:
Lives Independently _______
Family Care Program _______
CR/IRA (supportive ) ________
Assisted Living Facility _______
Lives with parents or other family ______
CR/IRA/ICF (supervised) ______
Nursing Home _______
Other (explain) ___________________________
(b) Does the Beneficiary receive community funds as part of residential care?
Yes____ No____ If yes, how much is it and how often received? _________________
8.
List other services that the Beneficiary receives (include day services, service
coordination, employment programs, etc.):
Service
___________________
___________________
___________________
CTI
Name of Provider
________________________________________
________________________________________
________________________________________
Page 3 of 12
Rev. 5/31/13
9.
(a)
Is there a court appointed Guardian for the Beneficiary? Yes____ No____
If yes, attach copy of Decree or Letters of Guardianship and complete the following:
Guardian of the:
□Person
□Property
□Both
If specific powers/authority is granted please list:
(Include dental and medical)________________________________________________
_______________________________________________________________________
If specific powers/authority is exempted please list:
(Include dental and medical)________________________________________________
_______________________________________________________________________
Please list name(s) and addresses of Guardian(s): _______________________________
_______________________________________________________________________
_______________________________________________________________________
(b) Are Standby Guardian(s) appointed?
If yes, for the:
□Person
Yes____
□Property
No____
□Both
Please list name(s) and addresses of Standby Guardian(s).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
(c) Are Alternate Standby Guardian(s) appointed?
If yes, for the:
□Person
□Property
Yes____
No____
□Both
Please list name(s) and addresses of Alternate Standby Guardian(s).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
10.
Relationship of Donor to Beneficiary? _______________________________________
11.
Would the Beneficiary like to receive a copy of monthly statements? Yes____
12.
List the individual to receive the “Beneficiary Binder”____________________________
No____
(Please note: One individual will receive a “Beneficiary Binder”. This may be sent to the
beneficiary or an alternate authorized individual. The binder contains a copy of the acceptance
letter, executed Joinder Agreement, Master Trust, disbursement request forms deposit slips,
etc.)
CTI
Page 4 of 12
Rev. 5/31/13
13.
AUTHORIZED CONTACTS: Please note that NYSARC, Inc. requires the Beneficiary
to have an authorized contact to speak to us on your behalf. Please note that the
Trustees in their discretion may require an intermediary to assist in the administration
of the Beneficiary’s sub-trust account.
List individuals below authorized to contact us on behalf of the Beneficiary?
(check all that apply)
Communicate
Receive
Statements
Submit
Disbursements
□
□
□
Name:
_________________________________
Address:
_________________________________________________________________
_____________________________________________________________________________
Telephone No. :________________________________________________________________
Relationship: _________________________________________________________________
Communicate
Receive
Statements
Submit
Disbursements
□
□
□
Name:
_________________________________
Address:
_________________________________________________________________
_____________________________________________________________________________
Telephone No.:_________________________________________________________________
Relationship: _________________________________________________________________
Communicate
Receive
Statements
Submit
Disbursements
□
□
□
Name:
_________________________________
Address:
_________________________________________________________________
_____________________________________________________________________________
Telephone No. :________________________________________________________________
Relationship: _________________________________________________________________
Person to contact in case of Emergency (REQUIRED IF NO ONE IS LISTED ABOVE):
(This individual will only be contacted if we are unable to reach you)
Name:
_________________________________________________________________
Address:
_________________________________________________________________
Telephone No.:_______________________________ E-mail: ___________________________
Relationship: _________________________________________________________________
CTI
Page 5 of 12
Rev. 5/31/13
14.
List an individual who will be submitting the Trust documents to Medicaid, Social
Security Administration, or other government agency on your behalf: (must be
knowledgeable in Medicaid Law, i.e., Attorney, Social Worker, Elder Care Consultant,
etc.) Please note: The individual listed below will receive a copy of the acceptance
letter in addition to a copy of the executed Joinder Agreement.
Name: _____________________________ Telephone No: _______________________
Agency/Firm, etc. ________________________________________________________
Address:
___________________________________________________________
___________________________________________________________
15.
Does the Beneficiary have funeral provisions in place? Yes ______
No _______
If yes, please include a copy of the funeral arrangements and provide as much detail as
possible.
.
Please provide name, address and phone number of the Funeral Home, submit a copy of
the funeral agreement and indicate status of funding:
________________________________________________________________________
________________________________________________________________________
Is there a burial plot for beneficiary? Yes ______ No _____
If yes, please provide the name and location of the cemetery and a copy of the deed for
the burial plot:
________________________________________________________________________
________________________________________________________________________
Additional information for items not listed above. Please provide as much detail as
possible:
________________________________________________________________________
________________________________________________________________________
(Please note this is for supplemental information for NYSARC, Inc. purposes only.)
16.
Is there a life insurance policy in place for the Beneficiary?
Yes___ No___
If yes, provide the name and address of the insurance company and the policy number:
________________________________________________________________________
________________________________________________________________________
CTI
Page 6 of 12
Rev. 5/31/13
Who is the owner of the policy? Please provide the name, address and phone number:
_____________________________________________________________________
_____________________________________________________________________
Please indicate whether whole life or term policy? ________________
What is the face value of the policy? ______________________
What is the cash value of the policy at the time trust is being established: ___________
Please provide the name(s), address and phone number (s) of the beneficiary(s) of the
policy?
_____________________________________________________________________
_____________________________________________________________________
CERTIFICATION:
I certify that the above information is accurate and complete to the best of my knowledge.
________________________________________
Donor/Beneficiary Signature
CTI
Page 7 of 12
_________________________
Date
Rev. 5/31/13
THE NYSARC, INC. COMMUNITY TRUST
(A TRUST FOR PERSONS WITH DISABILITIES)
Joinder Agreement
NOTE: THIS IS A LEGAL DOCUMENT. IT IS AN AGREEMENT PERTAINING TO A SUPPLEMENTAL
NEEDS TRUST CREATED PURSUANT TO 42 UNITED STATES CODE §1396. YOU ARE
ENCOURAGED TO SEEK INDEPENDENT, PROFESSIONAL ADVICE BEFORE SIGNING THIS
AGREEMENT. ADDITIONALLY, THE NYSARC, INC. TRUST SERVICES DEPARTMENT MAY NOT
ACCEPT THIS JOINDER AGREEMENT UNLESS YOU HAVE A LEGAL REPRESENTATIVE.
The undersigned hereby adopts, enrolls in and establishes a sub-trust account under the
NYSARC, INC. COMMUNITY TRUST I (“CT I”) dated, April 19, 1997, and as amended,
this Trust being incorporated herein by reference. THIS TRUST IS IRREVOCABLE.
1.
Name of Donor (Generally same as Beneficiary): _____________________________
Social Security No. of Donor: ____________________________________________
Date of Birth: _____/_____/_____
Address of Donor: _________________________________________________________
_________________________________________________________
Telephone Number of Donor: ________________________________________________
2.
Name of Disabled Beneficiary (In-Kind Beneficiary): ____________________________
Disabled Beneficiary’s Social Security Number: ________________________________
Date of Birth: _____/_____/_____
Address:_________________________________________________________________
_________________________________________________________________
Telephone Number (Day):___________________
3.
CTI
(Evening):___________________
Fees shall be paid in accordance with the published fee schedule.
Page 8 of 12
Rev. 5/31/13
4.
5.
6.
Death of Beneficiary
a.
The Beneficiary’s sub-trust account terminates upon his or her death. If,
upon the death of the Beneficiary, funds remain in his or her sub-trust account,
such funds shall be deemed to be property of the Trust and all funds that are
remaining in the Beneficiary’s separate sub-trust account shall be retained by the
NYSARC, INC. COMMUNITY TRUST I to further the purposes of the Trust.
However, to the extent that amounts remaining in the individual's account
upon the death of the individual are not in fact retained by the trust, the
trust shall pay to the State(s) from such remaining amounts in the account an
amount equal to the total amount of medical assistance paid on behalf of the
individual under the State Medicaid plan(s). To the extent that the trust does
not retain the funds in the account, the State(s) shall be the first payee(s) of
any such funds and the State(s) shall have priority over payment of other
debts and administrative expenses except as listed in the POMS SI
01120.203B.3.a.
b.
All final disbursement requests must be submitted within ninety (90) days of the
Beneficiary’s death and upon submission of the death certificate. Only expenses
incurred prior to the Beneficiary’s death will be considered.
c.
Funeral expenses will only be paid pursuant to a Medicaid eligible pre-need
funeral agreement established prior to the Beneficiary’s death. Funeral expenses
will not be paid after the Beneficiary’s death.
Contributions/Deposits:
a.
All contributions made to the Trust Account will be held and administered
pursuant to the provisions of the NYSARC, INC. COMMUNITY TRUST I
dated April 19, 1997 and as amended. The provisions of the NYSARC, INC
COMMUNITY TRUST I are incorporated herein by reference.
b.
The Trustees shall have the sole and absolute right to accept or refuse
additional deposits to the Sub-trust account.
c.
In the event that a Beneficiary has a zero ($0) sub-trust account balance for sixty
(60) or more consecutive days, the Trustee shall retain the right to close the
Beneficiary’s sub-trust account. Please be advised that the Trustee may
continue to charge administrative fees for the management of the sub-trust
account prior to its closure. In the event that a Beneficiary wishes to re-open a
sub-trust account, the Beneficiary may be required to pay any outstanding
administrative fees stemming from the prior sub-trust account. Additionally, the
Beneficiary shall be required to pay a new enrollment fee when re-opening a
sub-trust account.
Disbursements:
a. All disbursement requests shall be reviewed and approved on an individual basis.
b. Disbursements for expenses incurred prior to 90 days of submission of a
disbursement request form shall not be paid.
CTI
Page 9 of 12
Rev. 5/31/13
c. The Trustees, in their discretion, have determined that disbursements for the
following items shall not be paid: purchases of firearms, alcohol, tobacco, items
relating to illegal activity, bail, or restitution.
d. All disbursements shall be made at the sole and absolute discretion of the Trustees.
7.
Disability Determination:
In the event that a disability determination is required for Medicaid purposes, please be
advised that administrative fees shall be incurred while the determination of disability is
being made.
8.
Miscellaneous:
Amendments:
Provisions of this Joinder Agreement may be amended by the parties hereto in writing, so
long as any such amendment is consistent with the Master Trust.
Taxes:
9.
a.
The Donor acknowledges that contributions to the NYSARC, INC.
COMMUNITY TRUST I are not tax deductible as charitable gifts, or otherwise.
b.
Sub-trust 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 may be needed.
Disclosure of Potential Conflict of Interest:
There may be a potential conflict of interest in the administration of the Trust since the
Trust retains those funds remaining in the sub-trust account at the time of death of the
Beneficiary. Funds remaining in the Trust may be used to pay for ancillary and/or
supplemental services for Beneficiaries and potential Beneficiaries for which services
may be rendered by a Chapter of NYSARC, Inc. or by NYSARC, Inc. itself.
The Donor(s) executing this Joinder Agreement is/are aware of the potential conflicts of
interest that exist in the Trustee’s administration of the Trust. The Trustee shall not be
liable to the Donor or to any party for any act of self-dealing or conflict of interest
resulting from their affiliations with NYSARC, Inc. or with any Beneficiary or
constituent agencies and/or Chapters.
10.
CTI
Situs: The sub-trust account created by this Agreement has been accepted by the Trustee
in the State of New York and will be initially administered by NYSARC, Inc. and a
financial institution in the State of New York. The validity, construction, and all rights
under this Agreement shall be governed by the laws of the State of New York. The situs
of this Trust for administrative, accounting and legal purposes shall be in the County of
Albany, the County where the majority of meetings concerning establishment of the Trust
have occurred.
Page 10 of 12
Rev. 5/31/13
11.
Invalidity of any Provision: Should any provision of this Agreement be or become
invalid or unenforceable, the remaining provisions of this Agreement shall be and
continue to be fully effective.
I have received and reviewed a copy of the Community Trust I Master Trust prior to the signing
of this Joinder Agreement. I have also read the Information and Procedures and Questions and
Answers and acknowledge that I understand the contents of all of the trust documents. I also
understand that said documents may be amended from time to time.
By signing below, the Donor acknowledges that the Beneficiary is disabled as defined in
Social Security Law Section 1614 (a) (3) [42 USC 13822c(a) (3)]
Under penalty of perjury, all statements made in this document are true and accurate to
the best of my knowledge.
By signing below, you agree to the following:
The NYSARC, Inc. Community Trust I is a trust authorized to be used by individuals with
disabilities pursuant to federal and state law. By agreeing to accept a donor’s property
pursuant to this Joinder Agreement, NYSARC, Inc., agrees only to manage the trust funds
in accordance with the terms of the Master Trust Agreement and in compliance with
applicable federal and state law and regulation. It is the sole responsibility of the donor
and/or the donor’s representative to determine whether the donor is “disabled” as that
term is defined under federal law, to determine whether they have the legal authority to
transfer property to fund the trust, and the impact that a transfer of property to the
NYSARC, Inc. Community Trust I will have on the donor’s continuing eligibility for
government benefit programs.
NYSARC, Inc. is not assuming any responsibility as counsel for the donor or Beneficiary,
or providing any legal advice as it relates to the consequences of a transfer of property to
the NYSARC, Inc. Community Trust I.
The Trustees in their discretion may require an intermediary to assist in the administration
of the Beneficiary’s sub-trust account, the cost of which would be charged to that
Beneficiary’s sub-trust account.
The party authorized to speak with us on your behalf or the intermediary must notify
NYSARC, Inc., immediately upon your death and will be required to provide us with a
certified death certificate.
An individual requesting and/or receiving disbursements in contravention of the Master
Trust Agreement and the Joinder Agreement will be required to repay the amount
disbursed.
CTI
Page 11 of 12
Rev. 5/31/13
This Joinder Agreement and the participation of the Beneficiary in the NYSARC
Community Trust is an important legal decision that will have significant and lasting
consequences for the Beneficiary and as a result you may want to consider obtaining advice
from an attorney or another trusted professional adviser before entering into this
Agreement. By signing this Agreement you are acknowledging that you have had a full and
complete opportunity to confer with an attorney or other adviser and that no employee of
NYSARC, Inc. has provided you (or the Beneficiary, if different from the person signing
this Agreement) with any legal advice in connection with this Joinder Agreement, the
participation by the Beneficiary in the Community Trust or the suitability of such
participation by the Beneficiary in the Community Trust based upon the particular
circumstances of the Beneficiary.
If applicable, this document was translated from Latin American Spanish to English by:
________________________________
Print Name
________________________________
Sign
===================================================================
__________________________
_________________________
_____________
SIGNATURE OF DONOR/GUARDIAN
RELATIONSHIP TO BENEFICIARY
DATE
State of New York
County of _____________
)
) ss.
On this _______ day of _________________, 20_____, before me, the undersigned, a
Notary Public in and for said State, personally appeared, ________________________________
Personally known to me or proved to me on the basis of satisfactory evidence to be the
individual whose name is subscribed to within the instrument and acknowledged to me that
he/she executed the same in his/her capacity and that by his/her signature on the instrument, the
individual or the person upon behalf of which the individual acted, executed the instrument.
____________________________________
Notary Public
===================================================================
FOR OFFICE USE ONLY
____________________________________________
NYSARC, INC., as Trustee
______/______/______
DATE
Date Complete: ______/______/______
Date Accepted: ______/______/______
Initial Funding: $__________________
CTI
Page 12 of 12
Rev. 5/31/13