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