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Dutton & Casey Special Needs Trust Questionnaire

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This questionnaire is designed to help gather the information necessary to properly prepare a third-party supplemental needs trust (third-party SNT). Even for established clients, this questionnaire is extremely helpful in preparing a third-party SNT that will meet your objectives. Those questions that do not apply to you may simply be ignored. Please feel free to attach additional pages where space is insufficient, or to provide other information that you feel is relevant. Thank you.

SECTION 1 – INFORMATION ABOUT THE PERSON CREATING THE TRUST

A. PERSON CREATING THE TRUST (OR SPOUSE #1 FOR JOINT TRUST)

B. Spouse of Person Creating the Trust (Or Spouse #2 for a Joint Trust)

C. Additional Information

A. BENEFICIARY INFORMATION

(print name commonly used—for example, John Jamison Dough might use John Dough)

B. BENEFICIARY'S SPOUSE

C. BENEFICIARY'S UNDERLYING DISABILITY

D. BENEFICIARY’S BENEFITS

NEEDS-BASED FINANCIAL BENEFITS:

ILLNESS-BASED MEDICAL BENEFITS:

ENTITLEMENT-BASED FINANCIAL BENEFITS:

ENTITLEMENT-BASED MEDICAL BENEFITS:

SECTION 3 – PLANNING OBJECTIVES

Please describe your planning objectives to assist the beneficiary in the following areas. Keep in mind that a supplemental needs trust by its nature places all discretion in the hands of the trustee, with an advisory committee or care manager providing input and potentially providing oversight. It is important for the trustee to have specific information about your overall intent.

Please check all that apply.

A. RESIDENTIAL

ACCEPTABLE residential situations:

UNACCEPTABLE residential situations:

B. SOCIAL AND RECREATIONAL ACTIVITIES

C. FAMILY

If yes, “family” expenditures that you consider an appropriate use of trust funds (please check all that apply):

D. OTHER PLANNING OBJECTIVES

SECTION 4 – BENEFICIARY’S ASSETS

Please list all assets owned by the beneficiary, including market value and ownership.

Please enter address, co-owners (if any), and approximate value in dollar amount for each property.

L. GIFTS AND INHERITANCES

M. LAWSUIT SETTLEMENTS AND JUDGMENTS

Please list Type, co-owners (if any), and estimated value of each asset.

Description:

Please list type and balance of all other liabilities.

SECTION 6 – TRUSTED PEOPLE AND ENTITIES

A. FAMILY ADVISORS

Please list any other advisors.

B. OTHER TRUSTED PEOPLE AND ENTITIES

To help determine the most appropriate trust management system that fits your beneficiary’s unique needs, please list the names of the people and entities that you trust and believe can assist with securing or overseeing the beneficiary’s personal care and assist in making financial decisions.

If the circumstances warrant, it might be preferable to establish a system of checks and balances for personal and financial management with third-party SNT administrators, family, friends, social workers, financial advisors, and others to ensure the highest quality of care for the beneficiary, and to ensure the financial interests of the beneficiary are protected.

Please list the Name, Phone, Email, and Relationship for each trusted person or entity.

SECTION 7 – TRUST TERMINATION PROVISIONS

A. DISTRIBUTION UPON CHANGED CIRCUMSTANCES

If the law changes and the existence of the trust renders the beneficiary ineligible for benefits, what would you like to do? (select only one):

If the beneficiary becomes gainfully employed and no longer dependent on public benefits, what would you like to do? (select only one)

B. DITRIBUTION UPON DEATH

Select the following option if you want to allow the beneficiary to decide who will get the remainder of the trust assets when the beneficiary dies (this is called a testamentary power of appointment).

SECTION 8 – OTHER ITEMS TO INCLUDE OR DISCUSS

RELEVANT DOCUMENTS

Please bring the following documents (or any other documents you deem relevant) to our meeting, if available:

  • Will(s)
  • Deed to Residence
  • Latest Tax Returns
  • Insurance Policies
  • Bank or Brokerage Account Statements
  • Powers of Attorney
  • Trust Documents
  • Health Insurance Policies
  • Social Security Award Letters
  • Pension Statements

REFERRAL SOURCE

We look forward to learning more about your legal concerns and discussing how we can best assist you. If you have any questions as you prepare for your meeting, please do not hesitate to contact our office at 312-899-0950, or 847-261-4708 or www.duttonelderlaw.com.