Fill and Sign the Qualified Income Trust Fact Sheet Myflfamiliescom Form

Millers Trust Agreement The __________________ (Trustor’s Name) Irrevocable Income Trust This Trust Agreement is made the __________________ (date), by and between _____________________ (Name of Trustor), hereinafter referred to as Trustor, and _____________________ (Name of Trustee), a corporation organized and existing under the laws of the state of ______________, with its principal office located at ___________________ _________________________________________________________ (street address, city, county, state, zip code) , referred to herein as hereinafter referred to as Trustee. 1. Name of Trust This Trust shall be known as The _________________ (Trustor’s Name) Irrevocable Income Trust. 2. Transfer in Trust Upon receipt of all present and future Social Security, pension and other income, Trustor shall transfer same to Trust. Such property, hereinafter designated as the Trust Estate, shall be held by Trustee, in trust, for the uses and purposes and on the terms and conditions herein set forth. 3. Disposition of Principal and Income The Trustee shall administer and manage the Trust Estate, collect the income therefrom, and after payment of monthly bank services charges and income taxes owed by the Trust, apply and dispose of the net income and principal of the Trust Estate as required by the rules and regulations of the _______________ (Name of State) Department of Human Services, as those rules and regulations now exist or may hereafter be amended, as pertains to the establishment of an Income Trust pursuant to 42 United States Code 1396(p). 4. Additions to Trust All receipt of Trustor’s Social Security, pension and other income by the Trustee, when received and accepted by the Trustee, shall become part of the Trust Estate. 5. Termination of the Trust This Trust shall terminate upon the death of the Trustor, and all assets remaining in the Trust shall be distributed as follows: A. The Trustee is hereby directed to pay to the _______________ (Name of State) Department of Human Services an amount equal to medical payments made by the ________________ (Name of State) Department of Human Services to, or on behalf of, Trustor since the creation of the Trust. However, if the Trustor has resided in more than one State, the funds remaining in the trust are distributed to each State in which the Trustor received Medicaid, based on the State’s proportionate share of the total amount of Medicaid benefits paid by all of the States on the Trustor’s behalf. B. In the event that any funds remain after distribution as set forth in Article 5(A) above, the rest, residue and remainder of the assets of this Trust shall be distributed to ________________________ (name of beneficiary). 6. Irrevocability of Trust This Trust shall be irrevocable, and can only be amended or terminated by mutual agreement between ________________ (Name of State) Department of Human Services and Trustee . 7. Powers of Trustee The Trustee shall have the power to do all acts, institute all proceedings and exercise all rights, power and privileges that an absolute owner of the Trust would have, subject to the rules and regulations of the _______________ (Name of State) Department of Human Services as they now exist or may later be amended, as pertain to Income Trust pursuant to 42 U.S.C. 1396p. 8. Accounting The Trustee shall deliver annual statements of the administration of the Trust to Trustor and his duly authorized representative, and shall make its books and records accessible at any reasonable time to Trustor or his duly authorized representative. In addition, the Trustee shall prepare an annual fiduciary tax return. The Trust records shall be open for inspection and copying by the ________________ (Name of State) Department of Human Services, and the Trustee shall make periodic reporting to the _________________ (Name of State) Department of Human Services as required by the ________________ (Name of State) Department of Human Services. 9. Governing Law The validity, construction, effect and enforcement of this agreement and of the Trust created hereunder shall be determined by the laws of the State of _________________ (Name of State) . ____________________ (Name of Trustee), Trustee By:______________________________________ (Name and Office in Corporation) ___________________________________ (Name of Trustor) , Trustor (Acknowledgments before Notary Public)