First-Party Pooled Special Needs Trust Checklist for ...

First-Party Pooled Special Needs Trust Checklist for Process of Joining

SEND THE CHECKLIST TO CCT WITH THE ENCLOSED INFORMATION

Check that the following are provided:

Joinder Agreement ? Original, signed by the Grantor(s) in front of a notary. Complete the highlighted sections of the attached W-9 Form for the Beneficiary.

Fee Schedule ? Signed by the Grantor(s). Check(s): Enrollment Fee ? make payable to Commonwealth Community Trust. NOTE: If only one check can be dispersed, make the check payable to TCVA, trustee for CCT, fbo (Beneficiary Name) and CCT will deduct the Enrollment Fee from this deposit. For deposit into the trust sub-account make payable to TCVA, trustee for CCT, fbo (Beneficiary Name) ? when funding the trust sub-account.

Description of the Beneficiary's disability from a medical professional. For Supplemental Security Income (SSI) recipients, a copy of the Benefits Verification. For Medicaid recipients, a copy of the Medicaid eligibility letter or the Medicaid card. A copy of the Beneficiary's Social Security card, if available. Beneficiary's Life Care Plan, if applicable. Attorney Checklist ? Completed and signed by the attorney, if applicable.

The Following Legal Documents are required, if applicable:

Documentation for Guardianship, Conservatorship, and/or Power of Attorney. For Court Ordered Settlements, a copy of the proposed Court Order, and the entered order after the

hearing. For a Structured Settlement, provide a copy of the Qualified Annuity Contract. If qualification of the Trustee before the Clerk of Court and/or annual filings with the Commissioner of

Accounts are required by the Court, a copy of the Court Order. If the sub-account is being funded by a transfer from an existing SNT, a copy of the trust, and a copy of the

Court Order, if applicable. If custody arrangement exists for a minor Beneficiary, documentation of such arrangement or Court Order. For pre-need funeral or burial arrangements, provide policy information.

If you have any questions, please contact the CCT office.

Beneficiary Name: ____________________________________________________________

Completed by: _____________________________ Relationship: _______________________

Date: ______________________________

2/2018

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