SPECIAL NEEDS TRUST QUESTIONNAIRE

SPECIAL NEEDS TRUST QUESTIONNAIRE
BENEFICIARY INFORMATION:
Full Name

First Name Last 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

City State / Province

Postal / Zip Code Country
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

City State / Province

Postal / Zip Code Country

Public Benefits: What public benefits, if any

Social Security Retirement Social Security Disability (SSD) Supplemental Security Income (SSI) Medicare Medi-Cal Long 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 Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Full Name

First Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Full Name

First Name Last Name
Relationship:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Full Name

First Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name of Person Completing this Form:
Law Offices of Cheryl L. Walsh

31431 Rancho Viejo Rd., Ste. 102

San Juan Capistrano, CA 92675

Tel: (949) 240-9003; Fax: (949) 240-9083

Cheryl@WalshSeniorLaw.com
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