SPECIAL NEEDS TRUST QUESTIONNAIRE

Law Offices of Cheryl L. Walsh, APC
27282 Calle Arroyo, Suite 200
San Juan Capistrano, CA 92675
Phone: (949) 240-9003 Fax: (949) 240-9083
Cheryl@WalshSeniorLaw.com
SPECIAL NEEDS TRUST QUESTIONNAIRE
BENEFICIARY INFORMATION:
Full Name

First NameLast Name
How old was the Beneficiary when he/she sustained the injury leading to the disability/became disabled?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth:
Social Security #:
Diagnosis
Describe nature of disability:
TRUSTEE/CO-TRUSTEE INFORMATION:
Source of funds to be placed in Trust:
Name(s) of Proposed Trustee/Co-Trustees:
Trustee/Co-Trustee Information:
Name:
Social Security Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Public Benefits: What public benefits, if any

Social Security RetirementSocial Security Disability (SSD)Supplemental Security Income (SSI)MedicareMedi-CalLong term care services (nursing, foster, group Homes)Mental Health Services
What will funds be used for? What are the beneficiary's current needs?
Where will the funds be invested?
What month will the funds be received?
What county/court will the petition to approve the settlement and trust be filed in (if applicable)?
Who will sign the petition to establish the trust?
What is the address of the public agency providing services so that the documents can be sent to it for notice (include worker's names)?

Who are the closest relatives of the disabled beneficiary who must be sent the documents for notice? (Attach supplemental pages as required.)
Full Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Relationship:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Name of Person Completing this Form:
Should be Empty: