Master Special Needs Pooled Trust Enrollment

Master Special Needs Pooled Trust Individual Enrollment

Fields marked with an * are required

Supporting documents

Any supporting documents can either be mailed to Berkshire County Arc, PO Box 2, Pittsfield MA 01202 or emailed to mfrancoeur@bcarc.org.

Trust Applicant Information

Trust Applicant Information

First Name *

Last Name *

Social Security # *

Age *

Date of Birth *

Marital Status *

Address *

Email *

Phone *

Divider

Next of Kin *

Address *

Email *

Phone *

Divider

Residential Information

Residential Information

Current Living Situation (Select One) *

Home
Apartment
Assisted Living
Group Home
Nursing Home
Other

Does the applicant own real property? *

If yes, please complete following 6 questions. If no, leave following 6 questions blank.

Address of Property (leave blank if not applicable)

Does the applicant have a life estate in property? (If yes, submit copy of deed/title) *

Is the property currently occupied by someone other than the applicant?

Is the property being rented?

Is the property vacant and being sold?

If the applicant is living in a nursing home, is he/she planning on returning?

All home repairs...

All home repairs must directly and solely benefit the trust applicant. The trust cannot pay for home repairs or expenses when an applicant doesn't live in the home, and if anyone else is residing in the home, renting the home, or if the applicant has a life estate.

Has the applicant ever resided in another state? *

If yes, please provide state of residence and dates:

Divider

Does the trust applicant have a legal representative such as a:

Power of Attorney
Guardian/Conservator
Rep-Payee
Other

Name of Legal Rep

Address

Email Address

Phone

Is the trust applicant legally competent to sign documents? *

Is the above legal representative signing the Joinder Agreement? *

A copy of Power of Attorney...

A copy of Power of Attorney or Guardianship/Conservator Decree, Petition to Establish an Estate Plan and the Court Order authorizing creating and funding of a pooled trust must be submitted.

File Upload

Divider

DDS Service Coordinator

Does the Trust Applicant have a DDS Service Coordinator? If so:

Name

Address

Phone

Email Address

Trust Applicant Disability Information:

Trust Applicant Disability Information:

Please describe the applicant's Medical Diagnosis/Disability:

Intellectual:

Physical:

Mental Health:

Other:

A disability determination is required to join a pooled trust. Has a determination been made by Social Security? *

Has a MassHealth LTC disability determination been made? *

If no, who will be completing a LTC disability determination?

Divider

Benefit Info

Trust Applicant Benefit/Income Information

Social Security Disability Income (SSDI)

Monthly Amount:

Supplemental Security Income (SSI)

Monthly Amount:

Social Security Retirement Income

Monthly Amount:

Annuity/Pension

Monthly Amount:

Wages

Monthly Amount:

Other

Monthly Amount:

Please attach a copy of SSDI/SSI Social Security Award Letter

Please submit a copy of SSDI/SSI Social Security Award Letter.

File Upload

Divider

Does the trust applicant have any of the following insurances: *

MassHealth
Medicare
Other

If you selected other, please write in the trust applicant's insurance:

Does the applicant have a pre-paid funeral? *

Does the applicant have a Will? *

Pre-paid funeral

We strongly encourage all applicants to have a pre-paid funeral in place. Permission from MassHealth must be obtained to pay any funeral expenses post death. Submit copy of Will if applicable.

File Upload

Divider

Disbursement Information

Disbursement Information

Ability of applicant to request funds: *

Independent
Needs Assistance

If applicant is unable..

If applicant is unable to make independent requests, please list the person(s) who is designated and empowered to request funds on the person's behalf:

Name

Address

Phone

Relationship to Applicant

Name

Address

Relationship to Applicant

Other information you would like us to know or other comments:

Divider

Funding Information

Funding Information

Pooled Trust Deposit *

Source of monies (e.g.: savings, personal injury settlement, inheritance, etc) *

Please list what types of expenses the applicant will access the trust for: *

Remainderperson Information

Remainderperson Information:

Trust Remainder Beneficiaries are person(s) and/or entity(ies) who would receive any funds remaining after the applicant’s death after final closing costs, after the Trust’s remainder share (5% applicant dies within first 2 years) or (20% applicant dies more than 2 years after joining) is paid to Berkshire County Arc and after Medicaid have been satisfied. Please provide below the persons or entities who should receive any balance remaining.

Primary Beneficiary

Primary Beneficiary: If more than one, please send additional names, addresses, and percentages to mfrancoeur@bcarc.org.

Name *

Address *

Relationship to Applicant *

Percentage *

Specify what should happen with this share if he/she predeceases the applicant *

Secondary Beneficiary

Secondary Beneficiary: If more than one, please send additional names, addresses, and percentages to mfrancoeur@bcarc.org.

Name

Address

Relationship to Applicant

Percentage

Specify what should happen with this share if he/she predeceases the applicant

Divider

Reporting Information

Reporting Information:

When a pooled trust account is funded, there is a legal obligation to report it to the appropriate government agency, either Social Security Administration or Medicaid (MassHealth). The Berkshire County Arc Master Special Needs Pooled Trust attorney can submit the reporting documentation or if you prefer to have your own attorney address this, we can provide supporting documentation directly to your attorney. The fee for the legal work to complete your legal duty to report your account can be deducted directly from your trust account.

Please indicate below your preference *

I prefer to have the Berkshire County Arc trust attorney complete the reporting requirements for me.
I prefer to have my attorney complete the reporting requirements for me.

Divider

By signing below...

By signing below, I acknowledge that I understand that this is an irrevocable trust account, and I have read and understand the Schedule of Fees. Berkshire County Arc, as Manager of the Special Needs Pooled Trust, is the only person that can authorize a payment be made from a Trust Members account. At no time can a check be issued payable to the Trust Member directly and all disbursements are for the sole benefit of the Trust Member only. I further understand, that upon the death of the Trust Member, no further disbursements other than costs associated with closing the account may be made. This includes funeral related costs, which requires permission from MassHealth to reimburse. Under Massachusetts Law, please note that potential creditors of a deceased person have one year from the date of death to bring a claim against assets held in a self-settled trust. For that reason, Berkshire County Arc, Inc.'s policy is to wait until the anniversary of a deceased trust member's death has passed before making any distributions to any named remainder person(s).

It is the responsibility of the contact person to notify the Berkshire County Arc Inc., Master Special Needs Pooled Trust of any changes in the trust member's living arrangement, health status, or financial profile and needs. The Berkshire County Arc Inc., Master Special Needs Pooled Trust must also be notified prior to a change in the trust member's contact person.

Name of person completing form *

Relationship to Trust Applicant *

Please submit

Please submit this application along with the required one-time enrollment fee of either $500 if the trust applicant signs his/her own Joinder Agreement or $600 if a fiduciary agent signs the Joinder Agreement to: Berkshire County Arc, PO Box 2, Pittsfield MA 01202.

The application will be reviewed and if appropriate the Berkshire County Arc Trust attorney will draft a Joinder Agreement for signature.

Any supporting documents can either be mailed to Berkshire County Arc, PO Box 2, Pittsfield MA 01202 or emailed to mfrancoeur@bcarc.org.

HTML

If you are a human seeing this field, please leave it empty.