WESTERN NEW YORK COALITION POOLED TRUST APPLICATION

Transcription

1 WESTERN NEW YORK COALITION POOLED TRUST APPLICATION DEMOGRAPHICS Name of applicant: Home address: City County State Zip Telephone No.: Social Security #: Date of Birth: Sex: Male: Female: Marital status: Maiden Name: (S = Single, M= Married, W= Widowed, D= Divorced) Location of applicant: Number of People in Household RESPONSIBLE PERSONS or EMERGENCY CONTACT Name Relationship Address City County State Zip Home phone Work phone Address Bank Power of Attorney Health Care Proxy Durable Power of Attorney Guardian Guardian proceeding pending MEDICAL INFORMATION Nature and onset of your disability: Do you use Medical equipment? If so what? 1

2 Do you have any medical bills or medically related expenses? Explain Do you have home care? If yes, how often? Do you have a case manager? What agencies are involved with your care? MEDICARE #: Hospital coverage (Part A) Effective date Medical coverage (Part B) Effective date MEDICAID CASE # Medicaid CIN # Effective date Medicaid pending? Long-Term Care Insurance If yes, name of carrier: What is the name of your waiver program? INSURANCE COVERAGE Veteran Spouse Veteran? Other Medical Insurance examples: (BC, BS, IHA, HCP, EPIC, No Fault) (Please indicate any SNF coverage) Company / Insurer Certificate # Prescription Card () If yes, # 2

3 INCOME INFORMATION Indicate if received money from: Amount Wages, Salary (including overtime), Commissions, Self-employment Unemployment Insurance Benefits Supplemental Security Income (SSI) Benefits Social Security Disability Benefits Social Security Dependent Benefits Social Security Survivor s Benefits Social Security Retirement Benefits Railroad Retirement Benefits Retirement Benefits (Pensions) Dividends/Interest from stocks, bonds, savings, etc. Specify: Workers Compensation NYS Disability Veteran s Pensions/Benefits/Aid and Attendance Food Stamps Education Grants or Loans Specify: Contributions/Gifts (Received) Child Support Payments Alimony/Support (Received) Private Disability Insurance: Income from a Trust: (including income you are currently entitled to receive, or were entitled to receive in the past, that has not been distributed) Training Allotments Rental Income (Received) Other 3

4 RESOURCES INFORMATION Indicate if you: Have cash on hand: Amount Have a checking account(s) Have a savings account(s) or certificate of deposit(s) Have an irrevocable burial trust or fund Specify: Are named the beneficiary of a trust Expect to receive a trust fund, lawsuit, settlement, Inheritance or income from any other sources Specify: Have resources other than those listed above? Specify: SHELTER EXPENSES What is your Landlord s name, Address, and phone number Do you have a rent, mortgage or other shelter expense? Who? Do you have the following expenses separate from your rent or shelter expense? o Electricity o Gas o Other utilities (water, etc.) o Telephone o Air conditioning 4

5 Do you live in public/ section 8 housing? Specify: What money will be placed in the Trust and how often? (Lump Sum) (Monthly Income/Spenddown) (Periodic Payments) (Court ordered) How do you see the trust money being spent? OTHER EXPENSES Do you have, or would you like the trust to pay for: Cable Y N Travel expenses Y N Computer expenses Y N Subscriptions Y N Animal care Y N Medical care Y N Hobbies/collections Y N (companion/housekeeper) Other Expenses ADDITIONAL COMMENTS: Referral Source: Beneficiary, or Representative: Beneficiary s Attorney Signature Date Signature Date Please return completed Application to: People Inc. Attn. Pooled Trust 1219 North Forest Road Williamsville, NY