Special Needs Trust Form

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Pertinent Information to Appoint JFCS as Successor Trustee in the Special Needs Trust
Do you have a letter of intent?*
- Yes
- No
Comments about Letter of Intent
Do you have a Special Needs Trust established?*
- Yes
- No
When was Special Needs Trust prepared?*
Special Needs Trust prepared by whom?*
Who is the Trustee?*
What is the anticipated timetable for the transition to Successor Trustee?*
Comments about Special Needs Trust
Is the client conserved?*
- Yes
- No
If client is conserved, what areas of conservatorship?
Other legal appointments/nominations

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Areas of Information to Review Concerning:
Nature of disability*
Additional diagnoses*
Pertinent medical history*
Medications*
Current public benefits received*
Future public benefits desired*
Behavioral and safety concerns (aggression, self-injurious behavior, elopement, etc.)*
Level of support needed to live at home and in the community:*
- 24 hours per day
- Support a few hours per day
- Minimal support
- Support throughout the day
- Support a few hours per week
Comments about Level of Support
Potential Client's Current Schedule and Services Provided*
Potential Client's Employment History*
Finances available to cover needs/Funding Sources*
What is the source of funds?*
What is the estimated value of the funds?*
Additional financial resources
Have you had a financial projection performed to determine there are sufficient funds to last the beneficiary’s lifetime?*
- Yes
- No
What is the anticipated dollar amount that will be funded into the Special Needs Trust?*
When was the Financial Projection done?*
By whom?*
What is the source(s) of funds?*
Who manages the funds?*

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Attorney Contact Information
Name
First Last
Work Phone
Cell Phone
Email
Financial Advisor Contact Information
Name
First Last
Work Phone
Cell Phone
Email
Documents Ready to Submit
If you have any of the following documents, please submit them as attachments in an email to Ryan Berman, [email protected], and Rebecca Paul, [email protected], with the subject line―“SNT: Documentation/Individual’s Name”
Check List for Submission*
- Special Needs Trust
- Recent Evaluations or Assessments
- Financial Projection
- None of the Above
Email
This field is for validation purposes and should be left unchanged.

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Potential Client's Information