Fill and Sign the Medicaid Income Trust Form

INCOME TRUST T H I S T R U S T A G R E E M E N T , d a t e d t h i s _____ d a y o f _______________ , 20 _____ , between ________________________________ ("Grantor") (Social Security Number ___________________ ) residing at ________________________________________________ and ________________________________________ ("Trustee") residing at _______________________________________________________ . ARTICLE 1: CREATION OF TRUST 1.1 Trust Property. The Grantor hereby establishes a trust and directs that the Trustee (as hereinafter named) shall receive unto the trust all income due Grantor ("Trust Property") and the Trustee accepts such property as the initial Trust estate. The Trust Property shall be administered and distributed upon the terms and conditions set forth herein. 1.2 Additions to Trust. Grantor agrees to transfer to the trust all income she receives from any source including __________________________________________ and ___________________________________________ . No assets other than such income exists and no other assets will be transferred to this trust. ARTICLE 2: MANAGEMENT AND DISPOSITION OF TRUST ESTATE 2.1 It is Grantor's primary concern in drafting this trust is to care for _____________________________________________ (the "Beneficiary"), throughout the remainder of her life and to _____________________________________________ . 2.2 This trust is made pursuant to the provisions of Section 1917 (d) of the Social Security Act (42 U.S.C. 1396) and shall comply with all provisions and regulations pertaining thereto. Any provision of this trust which would render the trust invalid under said statute shall have no force or effect. 2.3 The trustee is authorized to disburse to the Grantor or for her use and benefit, an amount equal to $ _____ less than the Medicaid income limit existing on the date of the disbursement. 2.4 The trustee shall provide annual accounting to the _______________ Division of Medicaid to show all receipts and disbursements of the trust during the previous year. The accounting shall be provided to Medicaid within 30 days of each calendar year. 2.5 Administrative fees are limited to $ _____ per month and are intended to cover bank charges. Page 1 of 3 2.6 This Trust shall cease and terminate upon the death of Beneficiary, and thereupon, the Trustee shall distribute and deliver all of the principal and undistributed income to the _______________ Division of Medicaid. ARTICLE 3: TRUSTEE POWERS 3.1 In the administration of this Trust, the Trustee shall, in addition to the powers provided by the laws of the state of _______________ , as the same may be in force as of the date first set forth above, or as may thereafter be amended, have the following express powers: 3.1.1 To disburse to the Grantor or her benefit the sums mentioned in paragraph 2.3 of this Agreement. 3.1.2 To make final distribution to the _______________ Division of Medicaid of all remaining principal and income remaining in the Trust after the death of the Grantor. 3.1.3 To invest trust funds in any bank, checking savings or Certificates of Deposit provided that any joint payee shall be the United States Department of Medicaid. ARTICLE 4: TRUSTEE 4.1 Trustee. _____________________________ is hereby appointed as Trustee and hereby agrees to serve as Trustee of the Trust created herein. 4.2 Alternate Trustee Designation. In the event a vacancy exists in the office of Trustee, for any reason, _____________________________ shall act as alternate Trustee. 4.3 Eligible Substitutes. Any natural person or corporation authorized to administer trusts shall be eligible to serve as an alternate Trustee hereunder; provided, however, that under no circumstances shall the Beneficiary of the Trust hereby created be eligible to serve as Trustee hereunder. 4.4 Powers of Alternate Trustees. Every alternate Trustee shall have all the title, rights, powers, privileges and duties herein conferred or imposed upon the original Trustee without any act of conveyance or transfer. 4.5 Bonds Waived. The Trustee, including any alternate Trustee, shall be permitted to qualify without the necessity of giving a bond or other undertaking in _______________ or any other jurisdiction for the faithful performance of such Trustee's duties, or if any bond shall be required by law, statute or rule of court, without the necessary of sureties thereon. Page 2 of 3 ARTICLE 5: CONSTRUCTIONAL RULES 5.1 Governing Law. The laws of _______________ and of the United States of America shall govern all questions as to the validity and construction of all trusts created by this instrument. 5.2 Gender Neutral. Words in any gender shall be deemed to include the other gender; the singular shall be deemed to include the plural, and vice versa. 5.3 Headings. The section headings of this Trust Agreement are for reference purposes only and are to be given no effect in the constitution of interpretation of this Agreement. ARTICLE 6: TRUST TERMINATION The Trust hereby established may be terminated by the Grantor at any time and shall terminate on the death of the Grantor and final disbursement of all remaining assets. In the event the trust is terminated prior to the death of the Grantor, all assets remaining in the trust shall be paid to the United States Department of Medicaid up to the amount of the total of all Medicaid assistance paid by Medicaid on behalf of the Grantor. The Grantor reserves no right to amend, modify, or revoke this Trust in whole or in part as necessary to comply with Section 1917 (d) of the Social Security Act (42 U.S.C. 1396) or any other applicable law. Any modification of this trust must be approved by the _______________ Division of Medicaid. ARTICLE 7: BINDING EFFECT This instrument shall bind the respective heirs, personal representatives, successors and assigns of Grantor and the Trustee. IN WITNESS WHEREOF, the parties have executed this instrument on the day and year first above written and this trust is effective on the date executed. ____________________________________ ____________________________________ Attached hereto Page 3 of 3