Arizona Special Needs Trust Creation Questionnaire

Complete and submit this questionnaire to hire Richard C. Keyt to prepare an Arizona Third Party Special Needs Trust. This form is extremely important. Your accuracy and completeness in responding will help me best represent you. If there are sections you don’t know the answers to, leave them for when we meet to discuss this form. There are other questions we will ask, but this will get us started. THE GOAL OF A SPECIAL NEEDS TRUST IS TO PROVIDE A MANAGEMENT SYSTEM FOR AN INHERITANCE OR, SETTLEMENT PROCEEDS THAT A PERSON WITH DISABILITIES WILL RECEIVE, SO AS TO ENABLE THAT PERSON TO BE ENTITLED TO GOVERNMENT BENEFITS AND HAVE IMPROVED QUALITY OF LIFE.

Questionnaire Date(Required)

Who Is Submitting This Questionnaire

Name(Required)

First Last

Phone(Required)

Email Address(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship to Special Needs Person?(Required)

Information About the Special Needs Person aka Beneficiary

Beneficiary's Full Legal Name(Required)

Beneficiary's Gender(Required)

male

female

Beneficiary's Birth Date(Required)

Beneficiary's Age(Required)

Beneficiary's Social Security Number

Enter n/a if beneficiary does not have a sociall security number.

Beneficiary's Medicaid Number

Enter n/a if beneficiary does not have a medicaid number.

Beneficiary's Medicare Claim Number

Enter n/a if beneficiary does not have a medicare claim number.

Beneficiary's Citizenship(Required)

U.S. citizen

legal immigrant

Beneficiary's Government Benefits(Required)

Identify all government assistance programs that provide benefits to the person with disabilities (i.e. Medicaid; SSI; Food Stamps; HUD housing)

What Government Benefits Has Beneficiary Applied for?(Required)

In none, enter n/a

Determination of Disability(Required)

yes

Has there been a determination of disability by the Social Security Administration?

Where Does Beneficiary Live?(Required)

Beneficiary's Competency(Required)

a competent Adult

an competent Adult

a minor expected to be competent at majority

a minor expected to be incompetent at majority

Beneficiary's Parents

How Many Parents are Living?(Required)

both

one

none

Parent's Name(Required)

First Middle Last Suffix

Parent's Phone(Required)

Parent's Email(Required)

Enter Email Confirm Email

2nd Parent's Name(Required)

First Middle Last Suffix

2nd Parent's Phone(Required)

2nd Parent's Email(Required)

Enter Email Confirm Email

Parent's Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Trust Information

Name of the Trust(Required)

Don't recommend putting the name of the beneficiary in the trust name because sometimes the trust name may appear on a public record and it then discloses the name of the beneficiary.

Who Will be the Trustee of the Trust?(Required)

1st parent named above

second parent named above

neither of them

Legal Name of the Trustee?(Required)

First Middle Last Suffix

Trustee's Phone(Required)

Trustee's Email(Required)

Enter Email Confirm Email

Trustee's Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Successor Trustees?

If you want to name a co-trustee or one or more successor trustees enter the successor trustee(s) legal name and if he/she is to be the first, second or third successor trustee.

Trust Information

How Will the Trust be Funded?(Required)

Describe What Asserts will be Given to the Trust on Its Creation(Required)

Who Will Contribute the Assets to the Trust?(Required)

What Happens to Trust Assets if the Beneficiary Dies?(Required)

all to Beneficiary's children equally

all to Beneficiary's siblings equally

all to Beneficiary's spouse if married

none of the above

Assets can be paid to successors only after the Medicaid lien has been repaid (if there is a Medicaid lien).

Who Gets Trust Assets?(Required)

Our Fee

Our Fee for the Special Needs Trust(Required)

Our fee for preparing the Special Needs Trust is $3,500. To pay us your fee by Visa, Mastercard, American Express or Discover credit or debit card please click on this link keytlaw.com/pay to access our secure online web form.

Submit This Questionnaire(Required)

When you click on the Submit icon below our system will send an email to you and us that has all the information you entered into this questionnaire. Review the email and reply and say everything is correct or tell us any changes you want to make.