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

Address

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

Address

Address

Address