golden state pooled trust enrollment form & data ......the trustee will review this spending...
TRANSCRIPT
GOLDEN STATE POOLED TRUST Enrollment Form & Data Collection Sheet
REFERRING ATTORNEY (You must have an attorney to enroll for services)
Firm Name:Name:Address:City:State: Zip:
Primary Phone:Fax Number:Email:
Trust enrollment documents will be sent to this email
ESTABLISHED BY INDIVIDUAL
Full Name:Address:City:State: Zip:
Social Security Number:Date of Birth:Primary Phone:Alternate Phone:Email:
ESTABLISHED BY COURT County:Case #:Judge:
Matter of:
FUNDING SOURCE Funding Source:Amount: $Date to be funded:
Comments:
BENEFICIARY
Full Name:Address:City:State: Zip:
Social Security Number:Date of Birth:Primary Phone:Alternate Phone:Email:
DISABILITY Is beneficiary a Minor? •
Yes No
Does the beneficiary have legal capacity? • Yes No
Do you own your home? Yes No
CAPACITY Disability:
Date of Disability:
Do you require special medical equipment? Yes No
If yes, what type:_________________________
Do you require a companion for travel? Yes No
Please attach copies of Beneficiary’s:1. Benefit Eligibility Letters2. Benefit Eligibility Cards3. State Driver’s License4. Social Security Card5. Birth Certificate and/or Passport6. Any other pertinent benefit or identification documentation
Red entry fields are required. If not applicable, please type "N/A".
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BENEFITS Monthly AmountSocial Security Supplemental Security Income (SSI) Social Security Disability Income (SSDI) Medi Cal Medicare Food Stamps OtherIHSS
$$$$$$$
Hours/Month
PENDING BENEFITS Benefit Type: Estimated date:
ADVOCATE Beneficiary themselves Guardian or Conservator POA Professional Advocate
Full Name:Address:City:State: ZipRelationship to Beneficiary:
Social Security Number:Date of Birth:Primary Phone:Alternate Phone:Email:
SUCCESSOR ADVOCATE
Full Name:Address:City:State: ZipRelationship to Beneficiary:
Social Security Number:Date of Birth:Primary Phone:Alternate Phone:Email:
CASE COMMENTS:
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REMAINDER BENEFICIARIES Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
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CONTINGENT BENEFICIARIES Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:
Full Name:Address:City:State: Zip:Relationship to Beneficiary:
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SPENDINGPLAN
Tobefilledoutbythereferringattorney
Context
Inorderforustobetterunderstandthebeneficiary’suniquesituationandneeds,pleasefillouttheattachedSpendingPlan.Thisdocumentallowsustocollecthelpfulinformationaboutrecurringexpensesandanticipatedneeds.
Itisthetrustee’sjobtomanagefunds,makemoneyavailableforapprovedexpenses,andensurethatgovernmentbenefitsstayprotected.Pleasenotethatcertainexpenses,ifpaidforbythetrust,maynegativelyimpactgovernmentbenefitsorevenmakethebeneficiaryineligibletoreceivebenefits.
ThetrusteewillreviewthisSpendingPlanandmaychoosetodiscussitfurtherwiththereferringattorney,beneficiary,oradvocate.Alldisbursementswillbemadeatthediscretionofthetrustee.
Instructionsforthereferringattorney
PleasecompletethefullSpendingPlanwiththebeneficiaryand/orbeneficiaryadvocateandreturnittotheGoldenStatePooledTrustatshelley@gspt.org.Ifyouhaveanyquestions,youmaycontactShelleySunseriat(877)336-3096.
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Spendingplan:Recurringmonthlyexpenses
Pleaserecordallofthebeneficiary’srecurringmonthlyexpenses,regardlessofwhetherthetrustwillbepayingforthemornot.
RECURRINGMONTHLYEXPENSES–NOEFFECTONBENEFITS
Utilities Transportation/Auto Phone $ Gas $ Cable/Internet $ Repairs $
Tolls $ HouseholdExpenses Licenseandregistration $ Repairs $ Insurance $ Supplies $ Publictransportation $ Furnishings $ Taxis,etc. $ Appliances $ Loanpayment $ Gardeningservices $ Other $ Housekeepingservices $
Clothing Personal/MedicalCare Clothes $ Medications $ Personalhygiene $ Entertainment Otherpersonal/medicalcare $ Movies,concerts,museums,etc. $
$ Insurance Travel Life $ Air,train,etc. $ Medical $
Other Other $
TOTAL: $__________________
RECURRINGMONTHLYEXPENSES–MAYAFFECTBENEFITSIFPAIDBYTRUST
Housing Utilities Rent $ Heating $ Mortgage $ Electricity $ Insurance $ Trash/Garbage $ Taxes $ Water $
Sewer $ Food Groceries $ Restaurants $
TOTAL:$__________________
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Spendingplan:Anticipatedone-timeexpenses
Pleaserecordanyone-timeexpensesthatyouanticipateinthenearfuture.Thislistdoesnotneedtobecomprehensive,butitwillhelpusthinkaboutthebeneficiary’scashneedsoverthenextcoupleofyears.Wehaveprovidedafewexamplesbelow.
ANTICIPATEDONE-TIMEEXPENSES
One-timeexpenses Amount AnticipateddateExample:Newcomputer $600 WithinthenextyearExample:Newwintercoat $150 November2016Example:Stationarybike $1000 Spring2017Example:Acupuncture $150 July2016Example:Electiveeyesurgery $2000 2018
TOTAL:$__________________
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