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 E-Mail 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
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
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
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
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 14221 5