MARC Application Form for PLAN of Massachusetts and Rhode Island

PLAN of Massachusetts and Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

MARC Spec ial Needs P ooled Trust Appli c a t ion

(10/2013)

APPLICATION SUBMISSION

Please submit the completed application and required attachments along with a check payable to

PLAN of Massachusetts and Rhode Island for the enrollment fee:

• The fee is $600 for enrollments that do not involve a guardian, conservator, attorney-in-fact,

or other fiduciary or agent.

• The fee is $750 for enrollments that do involve a guardian, conservator, attorney-in-fact, or

other fiduciary or agent.

Please see the Informational Packet and/or Fee Schedule for a list of all fees.

PLAN of Massachusetts and Rhode Island will review the application and contact you if we require

any additional information. Once approved, a PLAN attorney will draft an Instrument of Trust

Assignment. This document will be forwarded to you along with instructions for establishing the

account.

Thank you for your interest in PLAN of Massachusetts and Rhode Island.

SECTION I: APPLICANT INFORMATION

APPLICANT’S CONTACT INFORMATION

Applicant’s

Name:

(Last)

(First)

(Middle Initial)

Current

Residence:

(Street)

(City, State)

(Zip Code)

Mailing

Address:

(Street)

(City, State)

(Zip Code)

Current Phone

Number(s):

(Home)

(Cell)

(Other-Please

Specify)

E-Mail

Address(es):

Applicant’s

Marital Status:

Single

Divorced

Widow/Widower

Married

Separated

Other (Please Specify):

________________________________________

Applicant’s

Children:

Yes

No

If yes, pl eas e list ho w m an y and their ages :

_______________________________________________

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 1 of 9

PLAN of Massachusetts a nd Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

APPLICANT’S RESIDENTIAL & WORK/DAY SETTINGS

Type of Residence:

Private Housing

Group Home

Specialized Foster Care

Nursing Home

Assisted Living Facility

Other – P lease Sp ec ify:

Work/Day Setting :

Employment – full-time

Employment – part-time

None

Da y Pro gram

Other – Pl ease Sp ec ify:

Providers

(if applicable):

Reside nti al Pro vi der:

Day Program Provider:

If the applicant is living in an institutional setting, is he/she expected to return to a community-based

setting?

YES NO If Y ES, please provide an anticipated date: ___________________

Does the applicant receive a housing subsidy of any kind? YES NO

If YES, what type and how much money is received per month? _____________________________

________________________________________________________________________________

Is the applicant currently on a waiting list for a housing subsidy? YES NO

Has the applicant ever lived in another state? YES NO

If YES, please list the state(s) and date(s) of residence:

State:

Date(s) of Residence:

APPLICANT’S AGE & DISABILITY INFORMATION

Applicant’s

SSN & Age:

- -

/ /

(Social Security #)

(Date of Birth)

Applicant’s

Disability:

Developmental Disability

Physical Disability

Mental Il lnes s

Other (P lease Sp ec ify) :

________________________________________

Applicant’s

Diagnoses:

Has the Social Security Administration (SSA) made a determination of disability? Yes No

If yes, pl eas e list the date o f determination: ___________________________________________

Is the applicant applying to SSA for a disability determination? Yes No Not Certain

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 2 of 9

PLAN of Massachusetts a nd Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

A

PPLICANT

’

S

B

ENEFITS

I

NFORMATION

Health Coverage:

Medicaid/MassHealth?

Yes No

Medicare? Yes No

Medicare Prescription Drug Coverage? Yes No

Private Health Insurance? Yes No

Dental Insurance? Yes No

Income &

Benefits:

Supplemental Security Income (SSI)?

Yes No Amt/month: $

Soc ia l Sec u r i t y Disa b il ity In c ome (SSDI)? Yes No Amt/month: $

Social Security (Retirement)?

Yes No Amt/month: $

Wages? Yes No Amt/month: $

Pension? Yes No Amt/month: $

Annuity? Yes No Amt/month: $

Other ? Specify: Yes No Amt/month: $

APPLICANT’S END-OF-LIFE ARRANGEMENTS

Does the ap pl ic ant ha ve a pre-paid funeral/burial contract? YES NO

Does the ap pl ic ant ha ve a Will? YES NO

REAL PROPERTY

Does the applicant own any real property? YES NO If yes, please check the appropriate box:

The property is currently occupied by someone other than the applicant

The property is being used as rental income

The property is vacant pending its sale

Other (pleas e expla in) _______ ______ _____ ______ _ _______ _____ ______ ___ _____ ______ ___

Please provide the address of the property. ______________________________________________

LIFE ESTATE INFORMATION

Does the applicant have a life estate in any real property? YES NO

If yes, please provide the address of the property: ________________________________________

________________________________________________________________________________

Is someone other than the benef ic i ar y living at the property? YES NO N/A

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 3 of 9

PLAN of Massachusetts a nd Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

SECTION II: SIGNOR AND REPRESENTATIVE INFORMATION

SIGNOR INFORMATION

Who will be signing the trust documents? (Please select one.)

Beneficiary Beneficiary’s Guardian/Conservator Beneficiary’s Power of Attorney

GUARDIAN/CONSERVATOR INFORMATION

If the applicant has a court-appointed guardian or conservator, please complete this section.

Please Note: If the GUARDIAN or CONS ERVATOR will be signing trust documents on behalf of

the ben eficiary, please submit the following with this applicatio n: Decree of

Guard ianship/ Conservatorship, Petition to Establi sh an Estate Plan, and the Court Order

approving the petition.

Guardian’s/Conservator’s

Name:

Guardian’s/

Conservator’s Address:

(Street)

(City, State)

(Zip Code)

Guardian’s/Conservator’s

Phone(s):

(Home)

(Cell)

(Other-Please

Guardian’s/Conservator’s

E-Mail(s):

Specify)

POWER OF ATTORNEY INFORMATION

If the applicant has a Power of Attorney/Attorney-in-Fact, please complete this section.

Please submit a copy of the Power of Attorney with the application . Additionally, if the

beneficiary has a Will, p le ase sub mit a copy of the Will with the application.

POA’s

Name:

POA’s

Address:

(Street)

(City, State)

(Zip Code)

POA’s

Phone(s):

POA’ s E-Mail

(Home)

(Cell)

(Other-Please

Specify)

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 4 of 9

PLAN of Massachusetts a nd Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

REPRESENTATIVE PAYEE

If the applicant has a representative payee, please complete this section.

Rep Payee’s

Name:

Rep Payee’s

Address:

(Street)

(City, State)

(Zip Code)

Rep Payee’s

Phone(s):

(Home)

(Cell)

(Other-Please

Specify)

Rep Payee’s

E-Mail(s):

SECTION III: FUNDING & DISBURSEMENTS

FUNDING THE TRUST ACCOUNT

Initial Deposit

to Trust:

$

Inheritance

Savings

Settlement

Other – Please Specify:

(Amount)

(Source of Funds)

Subsequent

Deposit(s):

(if applicable)

$

(Amount)

(Source of Funds)

Were any of the funds above subject to a Medicaid or Medicare lien? YES NO

Please Note: If YE S, please submit evidence with the application demonstrating that the lien has

been satisfied.

DISBURSEMENTS

After the trust account is established, PLAN’s Service Coordinator will contact the beneficiary or a

representative of the beneficiary to develop a spending plan and discuss the process for accessing

funds. Who should be contacted for this purpose?

Name:

Phone:

Email:

Relationship to Beneficiary:

Note: PLAN of Massachusetts and Rhode Island, Trustee, has total and sole discretion in making

payments from an individual’s MARC Special Needs Pooled Trust account. All payments must be

for the sole benefit of the trust beneficiary.

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 5 of 9

PLAN of Massachusetts a nd Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

SECTION IV: ATTORNEY INFORMATION

APPLICANT’S ATTORNEY

Attorney’s

Name:

Attorney’s

Address:

(Street)

(City, State)

(Zip Code)

Attorney’s

Phone(s):

(Work)

(Cell)

(Other-Please

Specify)

Attorney’s

E-Mail:

Will this attorney be involved with the beneficiary on an ongoing basis? YES NO

SECTION V: REMAINDERPERSONS

PRIMARY REMAINDERPERSONS/ORGANIZATIONS

Please provide the name of the person(s) or entity(ies) who the beneficiary wishes to receive any

funds remaining after the beneficiary’s death after final settlement costs, after the 10% (Trust

Beneficiary dies within two (2) years of joining the trust) or 20% (Trust Beneficiary dies more than two

(2) years after joining the trust) remainder to PLAN of Massachusetts and Rhode Island, and after all

Medicaid claims have been paid or settled. Please specify what percentage of the remaining funds

you wish each to receive. Percentages must total 100%.

Primary Remainderperson/Organization 1

Name:

Address:

(Street)

(City, State)

(Zip Code)

Relationship to

Applicant:

% of Remaining Funds:

If this remainderperson does not survive the beneficiary, what should happen to his/her share?

(Please check one.)

Share to be distributed to other (living) primary remainderpersons listed on this form, in proportion

to their respective beneficial interest.

Distribute this share to this remainderperson’s descendants.

Distribute this share to someone else:

Name:

Address:

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 6 of 9

PLAN of Massachusetts a nd Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

Primary Remainderperson/Organization 2

Name:

Address:

(Street)

(City, State)

(Zip Code)

Relationship to

Applicant:

% of Remaining Funds:

If this remainderperson does not survive the beneficiary, what should happen to his/her share?

(Please check one.)

Share to be distributed to other (living) primary remainderpersons listed on this form, in proportion

to their respective beneficial interest.

Distribute this share to this remainderperson’s descendants.

Distribute this share to someone else:

Name:

Address:

Primary Remainderperson/Organization 3

Name:

Address:

(Street)

(City, State)

(Zip Code)

Relationship to

Applicant:

% of Remaining Funds:

If this remainderperson does not survive the beneficiary, what should happen to his/her share?

(Please check one.)

Share to be distributed to other (living) primary remainderpersons listed on this form, in proportion

to their respective beneficial interest.

Distribute this share to this remainderperson’s descendants.

Distribute this share to someone else:

Name:

Address:

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 7 of 9

PLAN of Massachusetts a nd Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

ULTIMATE REMAINDERPERSONS/ORGANIZATIONS

Please identify the individual(s) or entity that will receive any remaining funds not distributed as

proved above. You must make a selection here.

The individual or charity of my choice (Include an address):

Name:

Address:

Relationship to Applicant (if individual):

My heirs at law.

REPORTING THE TRUST ACCOUNT

If the applicant receives SSI benefits and/or Medicaid, the establishment of this trust must be reported

to the appropriate agencies. A PLAN attorney can submit that report, or in the alternative, provide

supporting documentation to the applicant’s attorney for the report. The fee for either service is billed

to the Trust Beneficiary’s account.

• Do you w ant the PL AN atto r ne y t o submit the report to the relevant agency? YES NO

• Do you want the PLAN attorney to submit supporting documentation to the applicant’s

attorney?

YES NO

If the applicant’s attorney submits the report, please forward a copy to PLAN of Massachusetts and

Rhode Island.

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 8 of 9

PLAN of Massachusetts a nd Rhode Island

Planned Lifetime Assistance Network of Massachusetts and Rhode Island, Inc.

SECTION VI: APPLICATION PREPARATION & SUBMISSION

APPLICATION PREPARATION

Who completed this application form?

Name:

Address:

Phone Numbers:

(Home)

(Cell)

(Other-Please

Specify)

E-Mail:

Signature &

Date:

(Signature)

(Date)

What is your relationship to the applicant?

Applicant (Self)

Applicant’s Guardian/Conservator

Applicant’s Attorney-in-Fact (Power of Attorney)

Applicant’s Attorney

Other (Please Specify): ____________________________

How did you hear about PLAN?

Previous Experience wi th PLAN

Attorney ( P lease Sp ec ify) : ____ ___ ___ _____ ______ _____ ___ _

Family/Friend

Community Organization

Internet Search

Brochure/Newsletter about PLAN

Presentation/Workshop/Conference ( Pleas e Specify): ____ ______ _____ ______ _ _______ _

Other (Please Specify): ______________________________

Thank you for your inte rest in PLAN of Mass achusetts and Rhode Island.

1340 Centr e Street, Suite 102, Newton Centre, MA 02459

Phon e : (617) 244-5552 Fax: (617) 795-0589 E-mail: info@planofma-ri.org

Page 9 of 9

Fillable Printable MARC Application Form for PLAN of Massachusetts and Rhode Island

Fillable Printable MARC Application Form for PLAN of Massachusetts and Rhode Island