Those
who have known me for several years realize that I write articles in two
instances: first, when I have
participated in a seminar, and reduce my lecture notes to writing; and second,
whenever I have been asked the same question dozens of times, and need to
relate some of my thoughts on the subject.
Based
on that criteria, an article on special needs trusts could have been written
years ago. However, I avoided writing
about special needs trusts for several reasons. First, the law changes constantly, and I do not want to update my
articles on a quarterly basis (and I generally do not do so). Second, there are other lawyers who prepare
more special needs trusts than I, and I assume they probably know more about
the subject than I do. Finally, there
are no easy answers in estate planning for relatives who are disabled.
With
those qualifications in mind, I will discuss the topics of “How to Avoid
Becoming Disqualified for Benefits” and “Medicaid Recovery”. After these sections, I will mention what
some of my clients have done (the section labeled “Miscellaneous”). The final part of this article is a
questionnaire, which should be completed, in order to assist your estate
planner, and to force you to think about what sort of inheritance you want your
child to receive.
Let
me begin with finances, because that’s the major concern of all parents. Since most children who are disabled,
regardless of age, are receiving some sort of disability payment from social
security disability or from DHS, the question is, will my child be able to
inherit anything from me, and if so, how much?
The general rule of thumb is that persons receiving disability payments
can own no more than $2,000 in property, and can generally earn (W-2
earnings) no more than $810 a month. In
some instances, the child can own a car, a home, and other “exempt”
assets. In other instances, the child
cannot own anything. If the parents leave resources for the child via a special
needs trust, the child may be disqualified from receiving benefits, if the
trust provides for things other than food, clothing and shelter.
At
this point, let me state that there are solutions available for disabled
children, and there are answers to the conflicting provisions of the law. But every estate planner, including me,
needs to know specific information about the child in question. I have attached a questionnaire, which
should be completed in full (or at least those portions that are applicable to
your situation), and given to the estate planner, before you consider available
options.
If an inheritance is left to a disabled person who is receiving government assistance, the person may become disqualified from receiving government benefits if the inheritance is given in the wrong manner, or too much money or property is given. To avoid disqualification, you should consider the safe harbor Congress created in 1993, as part of the Omnibus Budget Reconciliation Act: the safe harbor permits gifts to disabled persons, if the gifts are made through the conduit of a Special Needs Trust. The trusts must be carefully drafted to comply with the requirements of the Social Security Administration Program Operating Manuals (POMs), and should be clear as to the types of distributions the trustee may make, so that the trustee does not unknowingly disqualify the beneficiary from public benefits.
Here is the resource for the safe harbor:
the Omnibus Budget Reconciliation Act of 1993 contains a provision, at 42
U.S.C. Sec.13996p (d)(4)(A), that
permits people who receive disability benefits from Social Security to retain
eligibility for Medicaid, in the form of a Special Needs Trust (which is also
known as a (d)(4)(A) trust, or a disability trust)..
The trust will contain the following provisions:
1. When the trust is
established and funded, it must solely benefit a disabled person who is under 65
years of age,;
2. The trust must be
established by the beneficiary’s parent, grandparent, guardian or a court
(presumably an aunt, uncle, or sibling could establish such a trust, which would
not be subject to the pay-back rules mentioned in paragraph 6);
3. The trust must contain
only the beneficiary’s money;
4. The trust must be
irrevocable;
5. Under the provisions of
the trust, the beneficiary must not be permitted to invade any portion of the
trust;
6. The trust must
provide that upon the beneficiary’s death, the Medicaid program will be paid
back for funds expended after the establishment of the trust.
If a trust meets these requirements, and for the purpose of determining
Medicaid and SSI (Supplemental Security Income) eligibility, income and
undistributed corpus will not considered as being available resources (assets)
for the beneficiary,. These trusts
are known as Special Needs Trusts, Medicaid Disability Trusts, or (d)(4)(A)
Trusts.
Most
of these trusts contain lots of “boiler-plate” language, which prohibits the
trustee from making any distribution which would disqualify the beneficiary
from receiving government benefits. The trusts generally permit distributions
for things which are not covered by the government, such as, dental care,
telephone services, and the like (there are probably close to 30 categories of
distributions the Trustee can make, without disqualifying the beneficiary from
receiving government payments). When
the disabled child dies, the remaining balance of the funds in the trust must
be paid to DHS.
If the beneficiary receives too much income, and is no longer qualified to receive government benefits, the beneficiary might consider creating a Miller trust, which in effect takes all excess income and assigns it to a special needs trust; when the beneficiary dies, whatever is left in the trust will be paid to DHS.
In sum, consider using a special
needs trust as a means of allowing your child to continue receiving government
benefits.
This portion of the article deals with disabled children who are receiving payments through Medicaid (not through Supplemental Security Income (SSI), Social Security Disability Income (SSDI), or other government programs). One of the requirements of the Omnibus Budget Reconciliation Act of 1993 is that states are required to recover the costs of nursing homes and other long-term care services from the estates of Medicaid beneficiaries. Simply put, states must attempt to be reimbursed for money spent through Medicaid programs, after the disabled child dies.
Every state is required to adopt its own set of rules, and delineate in what instances the state agencies will seek recovery of Medicaid payments that have been made to deceased beneficiaries. The concept of Medicaid recovery is explained in greater detail in a web article published by AARP, at http://research.aarp.org/health/d16443_estate_1.html.
Each state has its own set of rules. Rather than give you a synopsis of the Oklahoma Rules, I have reproduced them in this article (this portion of the article is in blue).
The web address where this information is located is rather long, but here it is: http://www.policy.okdhs.org/317_ch_35/317_35_19/317_OHCA_CHAPTER_3531735194_Medicaid_recovery.htm). You should go to this website for updates.
Oklahoma Estate Recovery Rules
(a) General overview.
The Omnibus Budget Reconciliation Act of 1993 mandates the state to seek
recovery against the estate of certain Title XIX recipients who received
medical care on or after July 1, 1994, and who were 55 years of age or older
when the care was received. The payment of Title XIX by the Oklahoma Health
Care Authority on behalf of a recipient who is an inpatient of a nursing
facility, intermediate care facility for the mentally retarded or other medical
institution creates a debt to the Authority subject to recovery by legal action
either in the form of a lien filed against the real property of the recipient
and/or a claim made against the estate of the recipient. Only Title XIX
received on or after July 1, 1994, will be subject to provisions of this part.
Recovery for payments made under Title XIX for nursing care is limited by
several factors, including the family composition at the time the lien is
imposed and/or at the time of the recipient’s death and by the creation of
undue hardship at the time the lien is imposed or the claim is made against the
estate. (See OAC 317:35-5-41(c)(6)(H) for consideration of home property as a
countable resource.) State Supplemental Payments are not considered when
determining the countable income. The types of medical care for which recovery
can be sought include:
(1) nursing facility services,
(2) home and community based services,
(3) related hospital services,
(4) prescription drug services,
(5) physician services, and
(6) transportation services.
(b) Recovery through lien. The Oklahoma Health Care
Authority (OHCA) may file and enforce a lien, after notice and opportunity for
a hearing, (DHS will conduct hearings) against the real property of a recipient
who is an inpatient in a nursing facility, ICF/MR or other medical institution
in certain instances.
(1) Exceptions to filing a lien. A lien may not be filed on
the home property if the client’s family includes:
(A) a surviving spouse residing in the home, or
(B) a child or children age 20 or less lawfully residing in the
home, or
(C) a disabled child or
children of any age lawfully residing in the home, or
(D) a brother or sister of the recipient who has an equity interest
in the home and has been residing in the home for at least one year immediately
prior to the recipient’s admission to the nursing facility and who has
continued to live there on a continuous basis since that time.
(2) Reasonable expectation to return home. A lien may be
filed only after it has been determined, after notice and opportunity for a
hearing, that the recipient cannot reasonably be expected to be discharged and
return to the home. To return home means the recipient leaves the nursing
facility and resides in the home on which the lien has been placed for a period
of at least 90 days without being re-admitted as an inpatient to a facility
providing nursing care. Hospitalizations of short duration that do not include
convalescent care are not counted in the 90 day period. Upon certification for
Title XIX for nursing care, DHS provides written notice to the recipient that a
one-year period of inpatient care shall constitute a determination by the
Department that there is no reasonable expectation that the recipient will be
discharged and return home for a period of at least three months. The recipient
or the recipient’s representative is asked to declare intent to return home by
signing the Acknowledgment of Intent to Return Home/Medicaid Recovery Program
form. Intent is defined here as a clear statement of plans in addition to other
evidence and/or corroborative statements of others. Should the intent be to
return home, the recipient must be informed that a one-year period of care at a
nursing facility or facilities constitutes a determination that the recipient
cannot reasonably be expected to be discharged and return home. When this
determination has been made, the recipient receives a notice and opportunity
for hearing. This notification occurs prior to filing of a lien. At the end of
the 12-month period, a lien may be filed against the recipient’s real property
unless medical evidence is provided to support the feasibility of his/her
returning to the home within a reasonable period of time (90 days). This 90-day
period is allowed only if sufficient medical evidence is presented with an
actual date for the return to the home.
(3) Undue hardship waiver. When enforcing a lien or a
recovery from an estate (see (C) of this Section) would create an undue
hardship, a waiver may be granted. Undue hardship exists when enforcing the
lien would deprive the individual of medical care such that his/her life would
be endangered. Undue hardship exists when application of the rule would deprive
the individual or family members who are financially dependent on him/her for
food, clothing, shelter, or other necessities of life. Undue hardship does not
exist, however, where the individual or his/her family is merely inconvenienced
or where their life style is restricted because of the lien or estate recovery
being enforced. Decisions on undue hardship waivers are made at DHS State
Office, Family Support Services Division, Health Related and Medical Services
Section.
INSTRUCTIONS
TO STAFF 317:35-19-4
The OHCA Legal Division staff will receive notification on all
undue hardship waiver decisions.
(4) Filing the lien. After it has been determined that the
recipient cannot reasonably be expected to be discharged from the nursing
facility and return home and the recipient has been given notice of the intent
to file a lien against the real property and an opportunity for a hearing on
the matter, a lien is filed by the Oklahoma Health Care Authority, Third Party
Liability Unit, for record against the legal description of the real property
in the office of the county clerk of the county in which the property is
located. A copy of the lien is sent by OHCA to the client or his/her
representative by certified mail. The lien must contain the following
information:
(A) the name and mailing address of the recipient, recipient’s
spouse, legal guardian, authorized representative, or individual acting on
behalf of the recipient,
(B) the amount of Title XIX paid at the time of the filing of the
lien and a statement that the lien amount will continue to increase by any
amounts paid thereafter for XIX to the recipient,
(C) the date the recipient
began receiving compensated inpatient care at a nursing facility or nursing
facilities, intermediate care facility for the mentally retarded or other
medical institution,
(D) the legal description of the real property against which the
lien will be recorded, and
(E) the address of the Oklahoma Health Care Authority.
(5) Enforcing the lien. The lien filed by the OHCA for Title
XIX correctly received may be enforced before or after the death of the recipient.
But it may be enforced only:
(A) after the death of the surviving spouse of the recipient or
until such time as the surviving spouse abandons the homestead to reside
elsewhere;
(B) when there is no child of the recipient, natural or adopted,
who is 20 years of age or less residing in the home;
(C) when there is no adult child of the recipient, natural or
adopted, who is blind or disabled as defined in, OAC 317:35-1-2 residing in the
home;
(D) when no brother or sister of the recipient is lawfully residing
in the home, who has resided there for at least one year immediately before the
date of the recipient’s admission to the nursing facility, and has resided
there on a continuous basis since that time; and
(E) when no son or daughter of the recipient is lawfully residing
in the home who has resided there for at least two years immediately before the
date of the recipient’s admission to the nursing facility, and establishes to
the satisfaction of the DHS that he or she provided care to the recipient which
permitted the recipient to reside at home rather than in an institution and has
resided there on continuous basis since that time.
INSTRUCTIONS
TO STAFF 317:35-19-4
(6) Dissolving the lien. The lien remains on the property
even after transfer of title by conveyance, sale, succession, inheritance or
will unless one of the following events occur:
(A) The lien is satisfied. The recipient or recipient’s
representative may discharge the lien at any time by paying the amount of lien
to the OHCA. Should the payment of the debt secured by the lien be made to the
county office, the payment is forwarded to OHCA/Third Party Liability, so that
the lien can be released within 50 days. After that time, the recipient or the
recipient’s representative may request in writing that it be done. This request
must describe the lien and the property with reasonable certainty. By statute,
a fine may be levied against the lien holder if it is not released in a timely
manner.
(B) The client leaves the nursing facility and resides in a
property to which the lien is attached, for a period of more than 90 days
without being re-admitted to a facility providing nursing care, even though
there may have been no reasonable expectation that this would occur. If the
recipient is re-admitted to a nursing facility during this period, and does
return to his/her home after being released, another 90 days must be completed
before the lien can be dissolved.
(7) Capital resources. Rules on the determination of capital
resources for individuals related to the aged, blind, or disabled (OAC
317:35-5-41) apply to the proceeds received for the property in excess of the
amount of the lien after the lien is satisfied.
(C) Recovery From Estates from estates.
(1) If the recipient was age 55 or older when the nursing care was
received, adjustment or recovery may be made only after the death of the
individual’s spouse, if any, and at a time when there are no surviving children
age 20 or less and no surviving disabled children of any age living in the
home. Oklahoma Statutes contain stringent time frames concerning when and how
claims against an estate in probate are filed and paid. Therefore, timely
updating of computer input forms indicating the death of the recipient is
crucial to insure the OHCA’s ability to file timely against the estate.
(2) The estate consists of all real and personal property and other
assets included in recipient’s estate as defined by Title 58 of the Oklahoma
Statutes. Although county staff ordinarily will not be responsible for
inventorying or assessing the estate, assets and property that are not
considered in determining eligibility should be documented in the case record.
(3) After updating of computer input form indicating recipient’s
death, a computer generated report is sent to OHCA/Third Party Liability(TPL).
This report will serve as notification to OHCA/TPL to initiate estate recovery.
(4) Undue hardship waivers
may be granted for estate recovery as provided in (b)(3) of the section.
MISCELLANEOUS
With the foregoing information in
mind, let me mention some techniques my clients have used, in dealing with
disabled children. Their primary
concern is, if a special needs trust is created and all of the trust funds are
not used for the benefit of their child, the residue of the trust funds must be
paid to DHS – and very few of my clients want unused funds to be paid to a
government agency.
One solution, which seems to be used
more than any other, is for the parents to disinherit the disabled child, in
the hope that the siblings or other heirs will use their inheritances to take
care of the disabled child. There are
many risks in doing this sort of thing, but this technique does keep the estate
from winding up in the hands of DHS.
The drawback to this technique is that all of needs of the disabled
child might not be met.
Another technique is to allot a sum
of money for the special needs trust (or to buy life insurance to be placed in
the special needs trust, when the parents die). The parents have the satisfaction of providing for the disabled
child, and perhaps this is the best of all solutions. The Trustee of the special needs trust will have the discretion
to make payments to or for the benefit of the disabled child, for things not
covered by SSI or other government benefit programs (such as vacations, sports
equipment, over the counter drugs, etc.).
A
trust is an agreement made between the settlor (grantor, trustor) and the
trustee, for the benefit of a beneficiary.
One very important issue a parent must decide is, who will serve as
trustee of the special needs trust when both parents die? Siblings or trusted relatives can certainly
serve, but if they are incapacitated, who will be the successor trustee? Trust companies are willing to serve as
trustee, but they charge minimum fees, and if the special needs trust is less
than $125,000, the annual fees charged (which are usually no less than $1,250)
may make the trust uneconomical.
There are several web based
resources that might shed more light on these topics: the National Special
Needs Network (www.nsnn.com) is an
informational site (apparently penned by a Florida lawyer), which contains some
basic information relating to special needs families. Some states have developed their own special needs network. These resources may help in the following
respects:
· Applying for estate and federal government
programs on behalf of family members with disabilities.
· Making certain there are adequate funds to
provide for family members, and safeguarding assets so that government benefits
will not be jeopardized or depleted.
· Selecting future living accommodations.
· Designating in writing an advocate/guardian.
The National Institutes of Health
(NIH) also provides significant resources and informative links on their
website, www.nih.gov,
as well as the Social Security web-site, www.ssa.gov, which offers a comprehensive guide on available programs guidelines and
eligibility, and how to apply for benefits.
Medicaid
and Medicare may provide options.
Medicaid is designed for people who satisfy income eligibility
requirements and, although the program is federally subsidized, it is
administered by DHS. Medicare, on the
other hand, is run by the Social Security Administration and may pay health
costs of people older than 65, as well as those younger than 65 who have received
Social Security benefits for at least two years.
To develop a
comprehensive plan for the care of disabled children, you will probably have to
assemble a group of professionals, including lawyers, accountants, health
professionals, and/or financial advisers.
I hope this article has at least given you some information you might
not have otherwise had.
When a disabled person receives money as
a result of a tort recovery or through equitable distribution or an
inheritance, the funds may cause the individual to lose eligibility for public
benefits. This
questionnaire will provide basic information for an estate planner.
A.
CONTACT PERSON
Name Date ____________________
Address ____________________
City State Zip ____________________
Home Phone No. Business Phone No. ____________________
E-Mail Address Fax No.
____________________
B.
PERSONAL INFORMATION ABOUT DISABLED PERSON
Name: ____________________
Address ____________________
City State Zip ____________________
Phone No. Social Security No. ____________________
Birth Date ____________________ Gender:
□ Male □ Female
Supplemental Security
Income (SSI) payments: __________________
Social Security
Disability Income (SSDI) payments: ____________________
Other government
benefit payments: _____________________
Other private benefit
payments: _____________________
Required medications:
__________________
Dietary restrictions:
___________________
Physical requirements
(special equipment, therapy, etc.): __________________
Known monthly
expenses: _____________________
C.
MISCELLANEOUS INFORMATION
1.
Is the disabled person living at home or in an institution? □
Home □ Institution If in an institution, please list:
Name of Institution ____________________
Address ____________________
City State Zip ____________________
Telephone No. ____________________
Name of Contact Person
____________________
2.
If the disabled person is living with either of his/her parents, what is
the marital status of the disabled person's parents? ____________________
3.
Is the disabled person a U.S. citizen? Yes
□ No □
4.
If the disabled person is not a U.S. citizen, is he/she a qualified
alien? □ Yes □ No □ Don't Know
5.
Has a guardian been appointed for the disabled person?
□ Yes □ No If so, please list:
Name of Guardian ____________________
Address ____________________
City State Zip ____________________
Telephone No. ____________________
If so, please attach
court orders, guardianship letters, and relative pleadings.
D.
PERSONAL INJURY ATTORNEY
Name of Attorney ____________________
Address ____________________
City State Zip ____________________
Telephone No. Fax No.
____________________
Email Address ____________________
E.
INSURANCE COMPANIES
(1) □ Health
□ Auto □ Other
Name of Company ____________________
Address ____________________
City State Zip ____________________
Telephone No. Fax No.
____________________
Name of Contact Person
____________________
Name of Policy owner ____________________
(2) □ Health
□ Auto □ Other
Name of Company ____________________
Address ____________________
City State Zip ____________________
Telephone No. Fax No.
____________________
Name of Contact Person
____________________
Name of Policy owner ____________________
F.
RIGHT OF SUBROGATION? □ Yes □
No
G.
Name of Initial Trustee ____________________
Address ____________________
City State Zip ____________________
Telephone No. Fax No.
____________________
Name of Alternate Trustee
____________________
Address ____________________
City State Zip ____________________
Telephone No. Fax No.
____________________
Name of Second Alternate Trustee
____________________
Address ____________________
City State Zip ____________________
Telephone No. Fax No.
____________________
H.
BACKGROUND OF INJURY
1. What was the date
of the injury and how did it occur?
____________________
____________________
2. Describe the nature
and extent of the injuries.
____________________
____________________
____________________
3. Describe the
disabled person's current physical, mental, and emotional condition.
____________________
____________________
____________________
4. Where does the
disabled person live and with whom?
____________________
____________________
5. What type of
medical services is the disabled person receiving?
____________________
____________________
____________________
6. What type of social
services is the disabled person receiving?
____________________
____________________
____________________
7. What is the
disabled person's prognosis?
____________________
____________________
8. Where will the
disabled person likely reside in the future?
____________________
____________________
9. Will nursing home
care probably be required? Yes □ No
□
10. What is the
disabled person's life expectancy? ____________________
11. Who are the
disabled person's present caregivers? Please describe them.
____________________
____________________
11.1. From whom is the
disabled person receiving home health care? □ Agency □ Family
Members
11.2. If from an
agency, please list:
Name of Agency ____________________
Address ____________________
City State Zip ____________________
Telephone No. Fax No.
____________________
Name of Contact Person
____________________
11.3. If the disabled
person is receiving care from family members, please list the following:
Name of Family Member
____________________
Address ____________________
City State Zip ____________________
Telephone No. ____________________
Is the family member a certified
health-care provider? Yes □ No □
12. Is the disabled
person mentally competent? Yes □ No
□
13. Does the disabled person have other significant health conditions (related or not)? Yes □ No □
If yes, please attach a copy of pertinent
past history.
14. Please attach any
accident reports.
15. Please attach any medical reports of the disabled person relating to the accident. Be sure to include the following:
·
Discharge summary from original hospital, if
applicable
·
Report from a medical examination at the time of
the diagnosis or injury
·
Report of the most recent medical examination by
a physician, preferably within six months
·
Reports of significant hospitalization,
surgeries, or rehabilitation from the date of the accident
I.
THE PLAINTIFFS
1. Is there more than
one plaintiff? Yes □ No □ If so,
who are they?
____________________
____________________
2. What is the nature
of their claims?
____________________
____________________
____________________
3. What are their
damages?
____________________
____________________
____________________
4.
If the plaintiff is a parent, does he or she have reimbursable
costs? □ Yes□ No If
so, for what?
____________________
____________________
5. Who is the tortfeasor? ____________________ Is there a qualified assignment? Yes □ No □
J.
THE SETTLEMENT
1. How much is the
overall settlement or judgment? ____________________
2. What are the costs?
____________________
3. What is the contingency
fee? ____________________
4. Are fees owed to
more than one lawyer? Yes □ No □
5. Will there be any
attorney liens filed in the case? □ Yes □ No
6. Will the amount of the settlement or judgment make the Plaintiff whole or will Plaintiff's injuries be permanent?
____________________
____________________
7. Is the settlement:
a lump
sum? □ Yes □ No
a structured settlement? □
Yes □ No
8. If there is no settlement, is there an offer? Yes □ No □ If yes, how much is the offer? ____________________ What does plaintiff's attorney realistically think the case is worth? ____________________
9. How much of the settlement is allocated to medical claims of the disabled person? ____________________
10. What is the
allocation of that portion of the settlement not allocated to medical claims of
the disabled person?
____________________
11. Has a lifecare
plan been prepared for the disabled person?
□ Yes□ No
If yes, please attach
a copy of any plan prepared for plaintiff's counsel and a copy of any plan
prepared for the defense.
K.
MEDICAID LIENS, MEDICARE CLAIMS, AND SUBROGATION CLAIMS
1. Was the plaintiff
receiving Medicaid at any time since the accident? Yes
□ No □
2. Is there a Medicaid
lien? Yes □ No □ If so, how much
is the Medicaid lien? ____________________
3.
Has Medicaid been notified of the commencement of the action or of the proposed
settlement, arbitration award, or jury verdict? Yes
□ No □ If so, please attach a
copy of the notice.
4. Has the Medicaid lien already been negotiated? Yes □ No □ Have any releases been signed? Yes □ No □
5. Was the plaintiff
receiving Medicare at any time since the accident? Yes
□ No □
6.
Is there a Medicare claim? Yes □ No
□ If so, how much is the claim?
____________________
7.
Has Medicare been notified of the commencement of the action or of the proposed
settlement, arbitration award, or jury verdict? Yes
□ No □ If so, please attach a
copy of the notice.
8. Has the Medicare claim already been negotiated? Yes □ No □ Have any releases been signed? Yes □ No □
9. Has Plaintiff received any benefits from worker's compensation? □ Yes □ No If yes:
Name of Carrier ____________________
Address ____________________
City State Zip ____________________
Telephone No. Fax No.
____________________
Name of Contact Person ____________________
10. Are there any insurance subrogation claims in the case? Yes □ No □ If yes, please describe the nature and extent of the subrogation claim. ____________________
11. Has the disabled person received any other government benefits? Yes □ No □ If yes, please describe the benefits.
____________________
____________________
12. Has the disabled person ever received Medicaid in any other state? Yes □ No □ If yes, please list the states in which Medicaid benefits were paid. ____________________
L.
COURT PROCEEDINGS
1. Do you believe
court approval of the settlement is necessary? □ Yes □
No If not, why not?
____________________
____________________
2. Assuming court approval is necessary, who are the interested parties? What are their names and addresses?
Name: ____________________
Address ____________________
City State Zip ____________________
Name: ____________________
Address ____________________
City State Zip ____________________
Name: ____________________
Address ____________________
City State Zip ____________________
3. Who signed the
engagement agreement with the plaintiff's counsel? ____________________
4. In which court is
the proceeding pending? ____________________
5. What is the docket
number of the case? ____________________
6. Who is the
presiding judge? ____________________
M.
PUBLIC BENEFITS
1.
Is anyone in the disabled person's household or immediate family
receiving public benefits? Yes □ No
□ Who? ____________________
2. What public
benefits are family or household members receiving?
____________________
____________________
3. What public benefits is the disabled person receiving? (Please list all public benefits: Medicaid, Special Waiver Programs, SSI (Supplemental Security Income), Social Security Disability Income (SSDI), Workers' Comp, Medicare, etc.
____________________
____________________
____________________
4.
Is it likely the disabled person will require public benefits in the
future? Yes □ No □
If
yes, why? ____________________
____________________
5. Does the disabled person have any income? Yes □ No □ From what source? ____________________
____________________
6. Has the disabled person made an application for public benefits that is still pending? Yes □ No □
7. Has the disabled person ever received public benefits (other than Medicaid) in any other state? Yes □ No □
If yes, list the states in which benefits
were paid and the nature of the benefit.
____________________
N.
EXPECTATIONS OF THE DISABLED PERSON
1. What does the
disabled person hope to achieve with this settlement?
____________________
____________________
____________________
2. What kinds of services does the disabled person now need that the plaintiff is not receiving?
____________________
____________________
____________________
3. What kinds of equipment or personal property does the disabled person hope to purchase with this settlement?
____________________
____________________
____________________
4. Where would the
disabled person like to be in two years?
____________________
____________________
____________________
5. If the disabled person is living with parents or a spouse, what kinds of equipment, personal property, or renovations would the parents or spouse like to see result from this settlement?
____________________
____________________
____________________
O.
ESTATE PLANNING
1.
Does the disabled person presently have any estate planning documents (wills,
trusts, powers of attorney)? Yes □ No
□ If yes, please attach copies.
2. Do the parents or
spouse have any estate planning documents? Yes
□ No □
If yes, please attach copies.
P.
WHO IS THE CLIENT?
1. Who will be the
client of [ name of law firm]?
Counsel? □
Yes □ No
Disabled
Person? □ Yes □ No
2. Will the fees of [
name of law firm] be carried as a cost? Yes
□ No □
3. Who is the
guarantor of the fees of [ name of law firm]?
____________________
Q. RESOURCES
1.
Does the disabled person presently have any health insurance, long term care
policies, annuities with long term care provisions? Yes
□ No □ If yes, please attach
copies, and delineate the coverages.
2.
Does the disabled person own any property, or is the person the beneficiary of
any trust? Yes □ No □
If yes, please list
all property owned, copies of any trusts, value of property owned, and any
debts of the disabled person.
3. Is the disabled person a veteran? If so, is there a VA Claim
Number? What sort of discharge did the disabled person receive (and
what was the basis for the discharge)? Does the disabled person have his or her
DD214?