The Arc of New Mexico POOLED MASTER TRUST I JOINDER AGREEMENT

Transcription

1 The Arc of New Mexico POOLED MASTER TRUST I JOINDER AGREEMENT This is a legal document. You are encouraged to seek independent, professional advice before signing. The undersigned hereby enrolls in, adopts and agrees to be bound by the terms of The Arc of New Mexico Master Trust I Agreement, dated April 9th, 1998, which is incorporated herein by reference and amended February 28, Trust Sub-account number (this number will be assigned by The Arc): Sponsor s Name/Address/Telephone Number/ Address: (The sponsor can be the parents, grandparents, legal guardian, courts or the beneficiary) Sponsor s Social Security Number: Sponsor's birth date: Relationship to Beneficiary: Beneficiary Information Name/Address/Phone: Social Security Number: Birth date: Place of birth: Hospital: Mother's name: Father's name: SSN: SSN: If the Beneficiary has a legal representative (e.g., legal guardian, conservator, representative payee or agent under a power of attorney), please complete: Name/Address: Relationship: Source of legal authority: legal guardian, conservator, representative payee, parent(s) agent under a power of attorney, other: Date of appointment: Does the Beneficiary receive Supplemental Security Income? Supplemental Security Income Social Security Disability Benefits Medicaid, Medicaid number: Developmental Disability Waiver List all other forms of government assistance that the Beneficiary receives:

2 The Arc of New Mexico Master Trust I, Joinder Agreement Page Two Is the Beneficiary covered under any policy of health insurance, if so please complete: Policy #: Insurer s Name/Address: If the Beneficiary is covered under any prepaid funeral or burial insurance plan, please complete: Policy #: What is the nature of the Beneficiary's disability? Beneficiary's medical diagnosis? What is the prognosis at this time? Permanent Distributions upon the Beneficiary's death: (section amended February 28, 2008) Upon the death of the Beneficiary, any amounts remaining in the Beneficiary's Trust Sub-account shall be held, administered and distributed as follows: Disposition at the Death of a Beneficiary. Upon the death of a Beneficiary, any amounts remaining in the Beneficiary s Trust Sub-account shall be held, administered and distributed as follows: Payment of Taxes and Expenses of Administration. First, the Trustee shall pay (1) taxes due from the Beneficiary s Trust Sub-account to the State or Federal government because of the death of the Beneficiary and (2) reasonable fees for administration of the Beneficiary s Trust Sub-account such as an accounting of the Trust Sub-account to a court, completion and filing of documents, or other required actions associated with termination and wrapping up of the Beneficiary s Trust Sub-account. Amounts to Remain in the Trust. Any amounts remaining in the Beneficiary s Trust Sub-account after payment of the expenses described in subparagraph above shall be deemed to be surplus Trust property and shall be retained by the Trust and, in the Trustee s sole discretion, used (a) for the benefit of other Beneficiaries, (b) to add indigent disabled persons, as defined in 42 U.S.C. 1382c(a)(3), to the Trust as Beneficiaries, or (c) to provide indigent disabled persons, as defined in 42 U.S.C. 1382c(a)(3), with equipment, medication or services deemed suitable for such persons by the Trustee. Medicaid Reimbursement. To the extent that amounts remaining in a Beneficiary s Trust Sub-account upon the death of a Beneficiary are not retained by the Trust, the Trust shall pay to the Medicaid program administered by the State of New Mexico (and any other state from which Beneficiary has received Medicaid assistance) all of such remaining amounts in the Trust Sub-account up to an amount equal to the total amount of Medicaid assistance paid on behalf of the Beneficiary. If the Beneficiary has received Medicaid assistance in more than one state, such remaining amounts shall be distributed to each state in which the Beneficiary received Medicaid assistance based on the state s proportionate share of the total amount of Medicaid assistance paid by all of the states on behalf of the individual.

3 The Arc of New Mexico Master Trust I, Joinder Agreement Page Three Uses for which Trust Sub-account distributions may be made: The supplemental needs plan established for the Beneficiary shall be incorporated by reference in this Joinder Agreement. The Trust Sub-account will be administered for the benefit of the Beneficiary. Pending the final preparation of an individualized supplemental needs plan established for the Beneficiary, any non-support items that are required for maintaining a Beneficiary's health, safety and welfare may be provided for the benefit of the Beneficiary when, in the discretion of the Trustee, such requirements are not being provided by any public agency, or are not otherwise being provided by any other source of income available to the Beneficiary. In addition, the Trustee may also make expenditures for the in-kind support and maintenance of a Beneficiary even if such expenditures would result in a reduction of a Beneficiary's government and/or private benefits but only to the extent that such expenditures do not result in the disqualification of a Beneficiary from government and/or private benefits for which the Beneficiary would otherwise be entitled. The Sponsor recognizes that all distributions are at the Trustee's sole discretion. With this in mind, the Sponsor expresses the following desires as to how funds in the Trust Sub-account might be used: 1. General Supplemental Needs: Any needs not met by benefits. 2. Specific Supplemental Needs Requested for the Beneficiary: Please attach list. 3. Additional supplemental needs, including items of a similar nature to those specified above that are specified in an individualized supplemental needs plan established for the Beneficiary and updated from time to time, may be provided if approved by Trustee. Miscellaneous The provisions of this Joinder Agreement may be amended as the Sponsor and Trustee may jointly agree, so long as any such amendment is consistent with the provisions of The Arc of New Mexico Master I Trust Agreement dated April 9, 1998 and the then applicable law. Taxes: a. The Sponsor acknowledges that the Trustee has made no representation to the Sponsor that contributions to the Trust are deductible as charitable gifts, or otherwise. b. Trust Sub-account income, whether paid in cash or distributed in other property, may be taxable to the Beneficiary (or to the Beneficiary's parents if used to satisfy a legal obligation of support) subject to applicable exemptions and deductions. Professional tax advice is recommended. c. Trust Sub-account income may be taxable to the Trust, and when this is the case, such taxes shall be payable from the Trust Sub-account.

4 The Arc of New Mexico Master Trust I, Joinder Agreement, Page Four If the Sponsor intends to enroll more than one Beneficiary under one Trust Sub-account, an additional agreement is required between the Sponsor and Trustee regarding such matters as the enrollment fees, annual renewal fees for unfunded enrollments, case management assessment fees, consultation fees, and Trustee administration fees. The Arc of New Mexico Master Trust I dated April 9th, 1998 and amended February 28, 2008, is a pooled trust in conformity with the provisions of 42 U.S.C. 1396p, amended August 10, 1993, by the Omnibus Budget Reconciliation Act of To the extent there is conflict between the terms of this Trust and the governing law as from time to time amended, the law and regulations shall control. Trustee fees will be charged in accordance with Schedule A attached hereto and as amended from time to time. Other Contacts/Information:

5 The Arc of New Mexico Master Trust I, Joinder Agreement Page Five IN WITNESS WHEREOF, the undersigned Sponsor has reviewed and signed this Joinder Agreement, understands it and agrees to be bound by its terms and the terms of The Arc of New Mexico Master Trust I Agreement, dated April 9th, 1998 and amended February 28, 2008, which it incorporates by reference, and The Arc of New Mexico, as Trustee, has accepted and signed this Joinder Agreement. x Sponsor x Sponsor STATE OF NEW MEXICO ) )ss COUNTY OF BERNALILLO ) Before me, the undersigned authority, on this day personally appeared, the Sponsor(s), known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that Sponsor executed the same for the purposes and consideration therein expressed. Given under my hand and seal of office this day of, 2013 Seal, Notary Public My commission expires: STATE OF NEW MEXICO ) )ss. The Arc of New of New Mexico COUNTY OF BERNALILLO ) Trustee Signed By: Before me, the undersigned authority, on this day personally appeared Jo Ann Baxter of The Arc of New Mexico, the Trustee, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that Trustee executed the same for the purposes and consideration therein expressed and accepted the foregoing Joinder Agreement. Given under my hand and seal of office this day of, Seal, Notary Public My commission expires:

6 Schedule A - Fee Structure The Arc of New Mexico Trusts Schedule A - Trust Fee Structure - Effective April 19, 2010 The Board of Directors of The Arc of New Mexico adopted a Fee Structure for all Trusts administered by The Arc of New Mexico, at its board meeting on April 16, Enrollment fee- Covers the cost of opening the account and preparing a beneficiary profile: There is a one time set-up fee of $250 for Master Trust I and any D4A Medicaid Trust where The Arc serves as Trustee. There is a one time set-up fee of $600 for Master Trust II and any third party trust where The Arc serves as Trustee. Annual fee - Charged for updating profiles, cost of maintaining account: The Arc will charge four percent (4%) of the value of a trust on an annual basis. This fee will be allocated to each trust account. These fees are subject to change at any time.