POOLED SPECIAL NEEDS TRUST

Transcription

1 POOLED SPECIAL NEEDS TRUST JOINDER AGREEMENT for a SELF-FUNDED SUB-ACCOUNT Good Shepherd Fund 1641 North First Street San Jose, CA (p) (f)

2 By this Joinder Agreement, on the day of,, 20 the undersigned hereby enrolls in and adopts the Good Shepherd Fund Master Pooled Trust. A copy of the Master Pooled Trust has been received, incorporated herein by reference and hereinafter referred to as the Trust. Trustee: Good Shepherd Fund, a California non-profit 501(c)(3) corporation headquartered at 1641 N. First Street, Suite 155, San Jose, CA Beneficiary: 1. Terminology The definitions of the terms used in this Joinder Agreement are located in the Appendix. 2. Beneficiary Information: Name: Address: US Citizen: Yes No Social Security #: Green Card: Yes No Primary Phone: Secondary Phone: DOB: Place of Birth: Age: Is the Beneficiary a minor or incapacitated? Yes No If the answer is Yes, the Trust must be established by a Statutory Representative, Attorney-in-Fact under a valid power of attorney, Guardian (with Letters of Conservatorship/Guardianship) or by Court Order. 3. Trust Establishment: Parent Attorney-in-Fact Beneficiary Grandparent Guardian Court 2 P a g e

3 4. Beneficiary s Primary Circle of Support: Relationship to Beneficiary: Name: Address: Phone: Relationship to Beneficiary: Name: Address: Phone: Relationship to Beneficiary: Name: Address: Phone: Relationship to Beneficiary: Name: Address: Phone: Relationship to Beneficiary: Name: Address: Phone: 3 P a g e

4 5. Beneficiary s Disability Info: Name of impairment or Disability: Nature of Disability: Date incurred (if applicable): Future Outlook: Please add any other comments about the beneficiary s condition: Beneficiary s Primary Care Physician: Practice: Name: Address: Phone: 6. Advocates: A Beneficiary should always have an advocate assigned. If the Beneficiary is Conserved (has a legally appointed guardian), that person s name might go here. If not, you may add a relative, friend, or if the Trust can financially assume the cost, ask Good Shepherd Fund to assign a care management representative. Oftentimes, Good Shepherd Fund is asked to assign one of our case management representative to look in on the Beneficiary. People living with disabilities are all too frequently the target of fraud and scandal. Our representatives will monitor the Beneficiary s living conditions, assess his/her peer group dynamics, help manage relational conflicts, review financial concerns, benefits concerns, etc. The Representative will also help the Beneficiary understand how to get the most out of their Trust. Oftentimes these visits take place in the community over coffee or lunch. Should you decide to have Good Shepherd Fund assign a case management representative, you may set the standard monthly interaction levels according to need, means, and desire below on the following page. Good Shepherd Fund requires two advocates be assigned. One primary and current, one successor advocate (unless the primary advocate is Good Shepherd Fund). 4 P a g e

5 Primary Advocate (leave blank if GSF has been assigned): Name: Address: Phone: Successor Advocate (leave blank if GSF has been assigned): Name: Address: Phone: Case Management Service Election $80.00/Hr. (Fill this out only if Good Shepherd Fund was assigned to an Advocate position) Estimated Cost 1 Visit per month $160 / mo 2 Visits per month $320 / mo Monthly telephone calls, with 1 face-to-face per quarter $95 / mo Other: 7. Trust Funding: Please indicate how the Trust is being funded below: Single Sum Contribution Amount: Date: Source: $ *If funding is coming from a structured settlement, use the 3 rd box below. Revolving, Incremental Contribution (for beneficiaries under 65) Please indicate the total gross amount of the expected income, and separate the line-items by source. 5 P a g e

6 Sources of Income: $ $ $ $ TOTAL gross monthly income: $ Settlement: If you selected this box, we will need a copy of the Settlement Agreement or Court Order for our files. Settlement Date: Settlement Amount: $ Periodic Payments: Yes No IF Yes: $ IF Yes: Monthly Quarterly Annually Other IF Other: 8. Beneficiary s Current Public Benefits: Please mark all that apply to the Beneficiary currently. You will need to attach a benefit statement or award letter for each entity that you check. None None at this time, but intend to apply Supplemental Security Income (SSI) Monthly Amount: $ Medicaid or MediCal Benefits List the Programs: Social Security Disability Insurance (SSDI) Monthly Amount: $ Social Security Retirement Income Monthly Amount: $ Other Pensions or Revolving Income List the Programs: Total Monthly Gross: $ Section 8 Housing Does a Spouse receive any of these? 6 P a g e

7 9. Trust Termination: Government Claims This Joinder Agreement represents a Self-Funded, or 1 st Party Special Needs Trust. As such, at the time of the death of the Beneficiary, as verified by the deceased s death certificate, Good Shepherd Fund will expense costs associated with wrapping up the trust. These may include applicable tax filings, submitting a final accounting to the court, filing documents, making notifications, or other administrative actions as required. Following these proceedings, State and Federal claims will be paid out of the remainder, for the purpose of reimbursing the Government for benefits the Beneficiary used during his/her life. Good Shepherd Fund shall distribute such remaining Trust property to each State in which the Beneficiary received government assistance, based on each State's proportionate share of the total government assistance paid by all of the states on the Beneficiary's behalf. Government repayment shall be given all priority over any other expenses to the degree enumerated in the statutes and government rules. 10. Trust Termination by Death of Beneficiary: In some cases, the Trust may have a surplus after the Government Claims referenced in section 9 have been satisfied. In such an event, the surplus shall be distributed according to the following distribution schedule: 100% to be retained by Good Shepherd Fund, to be used solely for the purpose of furthering the Conservatorship/Guardianship mission, benefiting persons with disabilities. 10% to be retained by Good Shepherd Fund, to be used solely for the purpose of furthering the Conservatorship/Guardianship mission, benefiting persons with disabilities. The other 90% is to be distributed according to the final remainder beneficiaries listed below: 11. Trust Termination by Early Termination: Any surplus in the trust after the government benefits claim referenced in section 9 shall be distributed to the beneficiary. Please note, all Final Remainder Beneficiary percentages must equal 100%. Distribution Percentage: % Beneficiary Name: Address: Social Security # Date of Birth: Phone: 7 P a g e

8 Distribution Percentage: % Beneficiary Name: Address: Social Security # Date of Birth: Phone: Distribution Percentage: % Beneficiary Name: Address: Social Security # Date of Birth: Phone: Distribution Percentage: % Beneficiary Name: Address: Social Security # Date of Birth: Phone: Distribution Percentage: % Beneficiary Name: Address: Social Security # Date of Birth: Phone: Distribution Percentage: % Beneficiary Name: Address: Social Security # Date of Birth: Phone: 8 P a g e

9 The Final Remainder Beneficiaries shall be as set forth in Section 12(c) above. Notwithstanding the foregoing, the Final Remainder Beneficiaries will only be entitled to a distribution from the Beneficiary s sub-account after all amounts have been paid to or for the Trust, Trust expenses and Government Reimbursement Claims, if any. 12. Trust Administration Fee Schedule Monthly Revolving Good Shepherd Fund charges a monthly revolving baseline fee of $ per account. This fee pays for obligatory administrative and accounting functions required by law. Third-Party The services of third-party professionals may be required from time to time. Referrals for a third-party review or other service may be made by Good Shepherd Fund s Professional Fiduciary, the Probate Courts, the Beneficiary, or his/her guardian. Fees associated with third-party intervention are customarily paid by the Sub-Account. Closing Costs Good Shepherd Fund does not assess a set closing fee. Rather, when the subaccount draws down to $5,000 or less, a spend-down plan will be negotiated. Good Shepherd Fund will, at that time, retain 10% to offset closing costs (final accountings and IRS filings). The remainder will be distributed according to the spend-down plan. Should the beneficiary die before the sub-account has been spent, Good Shepherd Fund will close the account according to the terms specified in the Joinder Agreement and Master Pool Trust. Code Time Hourly Rate Total Clerical CL 0.67 $65.00 $43.55 Internal Accounting IA 0.33 $95.00 $31.35 Conservatorship / Guardianship CG 0 $80.00 $0.00 Administrative AD 0.17 $ $17.85 Professional Fiduciary PF 0.08 $ $10.00 Monthly Revolving Fee 1.25 $ * Included Services Account Maintenance Encrypted, Security Compliant Cloud-based Data Storage Professional Fiduciary Oversight (Required by law) Investment Oversight Monthly bank/earnings reconciliations Monthly distributions (up to 2) Quarterly Report Prep & Handling Postage, copies, and file storage Quarterly distributions (up to 6) Year-end tax prep (not including 3rd party fees & applicable taxes) Annual Accounting Additional services are added according to utilization One-Time Fees Trust Establishment $ Investment Services Good Shepherd Fund utilizes the services of UBS Financial, a global leader in the financial services industry, to manage and execute our investment strategy. The all-in investment charge is 1.5% annually, which includes management fees, custodial costs through UBS, 3rd Party Fees 3rd Party Fees, such as legal or external accounting are passed through on a needs basis * GSF provides a 50% discount to funds at or below $5,000, provided there is a spend-down plan in place. transaction and commission costs, co-fiduciary and advisory costs through UBS, rebalancing as per IPS, and Good Shepherd Fund s investment accounting requirements. 9 P a g e

10 13. Acknowledgments: The Beneficiary, individually, and on behalf of the Beneficiary the Grantor(s), and all interested Stakeholders acknowledge and agree that: a.) They have received copies of the Master Pooled Trust and this Joinder Agreement, and have been advised to have these documents reviewed by an independent attorney representing Grantor/Beneficiary s best interests. b.) The Parties recognize and acknowledge the uncertainty and changing nature of the guidelines, laws, regulations and rules pertaining to government assistance benefits. They each agree that the Trustee will not in any event be liable for any loss of benefits as long as the Trustee acts in good faith. c.) The Parties acknowledge and agree that The Good Shepherd Fund as an organization, its officers, directors, advisory council, employees, agents and their heirs, legal representatives, successors and assigns (hereinafter referred to as Qualified Persons ) shall not in any event be liable to the parties representing the Beneficiary, or any other person for their acts as long as their acts are reasonable and made in good faith. d.) The Beneficiary and/or the parties representing the Beneficiary acknowledge that upon execution of this Joinder Agreement and the funding of the Trust Sub-Account for the Trust Beneficiary, the contribution is irrevocable. All parties further acknowledge that after the funding of a Trust Sub Account, they shall have no further interest in and do thereby relinquish and release all rights in, to, control over, and all incidents of ownership and interest of any kind or nature in and to the contributed assets and all income thereon. e.) The Beneficiary and/or the parties representing the Beneficiary have not been provided nor are they relying upon any representation of, or any legal advice given by Good Shepherd Fund in deciding to execute this Joinder Agreement, but have obtained independent legal advice. f.) The Beneficiary and/or the parties representing the Beneficiary has entered into this Joinder Agreement voluntarily as their own free act and deed, and; g.) If the Beneficiary and/or the parties representing the Beneficiary have not had the Master Trust and the Joinder Agreement reviewed by an independent attorney, they have voluntarily waived and relinquished such right; 14. Effective Date: The effective date of this Joinder Agreement shall be the date on which the Joinder Agreement is accepted by Good Shepherd Fund. Provided, however, if the Contributed Amount is not received by the Trustee, Good Shepherd Fund shall have the right to rescind its acceptance and its obligations under the Master Trust and the Joinder Agreement shall be cancelled, without further obligation on its part. Upon cancellation, all fees due and payable shall have been paid in full. 10 P a g e

11 IN WITNESS WHEREOF, the undersigned Grantor has reviewed and signed this Joinder Agreement, understands it and agrees to be bound by its terms. Good Shepherd Fund has signed this Joinder Agreement effective on the date as first above written. GRANTOR Disabled individual, signing as Grantor Attorney-in-Fact Parent Grandparent Guardian Court TRUSTEE Sign: Sign: Print: Print: Tom P Avramis President & CEO Address: Good Shepherd Fund Below this line for notary use only A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California ) County of ) On_ before me, DATE NAME AND TITLE OF THE OFFICER personally appeared NAME(S) OF SIGNER(S) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Place Notary Seal Above Signature Signature of Notary Public 11 P a g e

12 APPENDIX A Terminology 1. Attorney-in-Fact means the person duly nominated in a Durable Power of Attorney having the power to act on behalf of the Beneficiary for all financial purposes, including the execution of the Master Trust and the Joinder Agreement. The Durable Power of Attorney is validly executed, and has not been rescinded, revoked or cancelled and the nominating principal has not been adjudicated incompetent and/or there is no pending proceeding pending to determine competence at the time this document is executed. 2. Beneficiary means a disabled person as defined in 1614(a)(3) of the Social Security Act (42 U.S.C. 1382c (a)3)) and who qualifies as a recipient of services and benefits under this Trust under 42 U.S.C. 1382b, as amended by the Foster Care Independence Act of 1999 (FCIA 99), and any amendments thereto. If the Social Security Administration or any authorized governmental entity has not made a determination that the beneficiary is a disabled person, the Trustee is authorized to accept such beneficiary within its discretion if it has made a determination that the beneficiary is a disabled person, as defined in 42 U.S.C. 1382c(a)(3). 3. Advocate means the person and successor persons, as may be applicable, named in the Joinder Agreement. The Beneficiary Advocate can, for example, be the Beneficiary himself or herself, but preferable the Beneficiary s Legal Representative or another person other than the Trust Beneficiary should act as the Beneficiary Advocate. The Trustee is authorized to communicate and to obtain advice and instructions from the Beneficiary Advocate with regard to a Trust Beneficiary s investment interests, health care, social activities, care management, residential options and other issues relating to the life care of the Trust Beneficiary. Provided, however, the Trustee has the right to exercise its discretion whenever the Trustee believes appropriate even though contrary to the advice of the Beneficiary Advocate. 4. Trust Funding refers to the initial amount and any subsequent amounts contributed or transferred to the Trust and placed in a Trust Beneficiary s sub-account. 5. Disabled Person means a person having a physical or mental impairment that complies with the requirements of 42 U.S.C. 1382c(a)(3) set forth in item 3 above Government Assistance means any and all services, medical care, benefits and financial assistance that may be provided by any county, state or federal agency, now or in the future, to or on behalf of a Beneficiary. Such benefits include but are not limited to the Supplemental Security Income (SSI) payments, Medicaid or other similar governmental programs providing public and/or medical assistance benefits, programs covering mental health, retardation and persons with disabilities. 7. Grantor refers to the person (Beneficiary, parent, grandparent, guardian or court order) who on behalf of the Beneficiary has the legal authority to adopt the Master Trust and Joinder Agreement. For the purposes of the Trust, a Beneficiary is considered to be the Grantor for all purposes and either name (Beneficiary or Grantor) may sometime be used interchangeably. The Beneficiary is considered to be the Grantor even though the contribution is made on the Beneficiary s behalf by a Beneficiary s parent, a Beneficiary s grandparent, a Beneficiary s guardian, or by a court regardless of the source. 8. Sub-Account means the financial account within the Trust maintained for the benefit of an individual Beneficiary and shall be equal to the initial value of the assets contributed on the Beneficiary's behalf less disbursements made on behalf of the Beneficiary, increased by earnings and appreciation, less taxes, expenses, depreciation and fees as set forth in the Joinder Agreement. 9. Joinder Agreement is the agreement by which a Beneficiary enrolls as a participant in the Trust. The agreement is between the Trustee and the Beneficiary (or the Beneficiary s Legal Representative). The Joinder Agreement establishes a sub-account with the Trust for the benefit of a disabled Trust Beneficiary. The Joinder Agreement also contains information about the Beneficiary, the Beneficiary s Legal Representative (if any) and the Advocate and any final Remainder Beneficiaries, as well as information about the rights and obligations of all parties involved. The Trustee and the Beneficiary or the Beneficiary s Legal Representative are required to sign the Joinder Agreement. 10. Legal Representative means a legal guardian, natural guardian, conservator, agent acting under a durable power of attorney, trustee, representative payee, custodian under the Uniform Gift or Transfers to Minors Act of any state, or other person caring for a Beneficiary who can act on behalf of a Beneficiary for the purpose of making binding agreements with the Trust. 11. Money Managers refers to the financial organization managing the assets in the sub-account in accordance with federal and state law and providing investment advice. 12. Reimbursement Claims or Government Reimbursement Claims refers to the applicable claims or liens of any governmental agency which is entitled to reimbursement for benefits paid to or for the benefit of a Trust Beneficiary because of being a participant of the Trust. 13. Remainder Amount means all of the remaining funds, if any, in a sub-account of a deceased Trust Beneficiary or a subaccount that has been terminated. 14. Trust or Master Trust refers to the Amended and Restated Declaration of the Good Shepherd Fund Pooled Special Needs Trust. 12 P a g e