The Corporation of Guardianship, Inc., Umbrella Pooled Trust JOINDER AGREEMENT A.
Adoption of Pooled Trust: The undersigned hereby enrolls in and adopts The Corporation of Guardianship, Inc., Umbrella Pooled Trust Declaration of Trust dated December 9, 2003, which is incorporated herein by reference, in which The Corporation of Guardianship, Inc., is Trustee. The Trust shall be irrevocable. This Trust is a pooled trust, governed by the laws of North Carolina, in conformity with the provisions of 42 U.S.C. §1396p, amended August 10, 1993, by the Omnibus Budget Reconciliation Act of 1993. To the extent there is conflict between the terms of this Trust and the governing law, the law and regulations shall control.
B.
C.
Grantor: Name:
________________________________
Address & Phone:
_______________________________ _______________________________ _______________________________ _______________________________
SSN:
______________________________
Beneficiary: Name:
________________________________
Address & Phone:
_______________________________ _______________________________ _______________________________ _______________________________
SSN:
______________________________
DOB:
______________________________
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D.
Representative(s): Conservator, Guardian, or Attorney-in-Fact: 1. Primary Name:
________________________________
Address:
_______________________________ _______________________________ _______________________________
Telephone:
_______________________________
2. Alternate
E.
Name:
________________________________
Address:
_______________________________ _______________________________ _______________________________
Telephone:
_______________________________
Source of Initial Funds: Select One:
Grantor’s assets /Beneficiary’s assets/ Settlement Proceeds
in the amount of approximately $_______________. F.
Distributions to Beneficiary: Distributions of principal and income will be made to the Beneficiary in Trustee’s discretion pursuant to the terms of the Trust and only in a manner that will not eliminate eligibility for the Beneficiary for public assistance programs (such as SSI and Medicaid).
G.
Distributions of the Remainder upon Death of Beneficiary: To the extent this Pooled Trust Sub-Account is funded with the Beneficiary’s own money, 42 U.S.C § 1396p(d)(4)(C) requires that any assets remaining in a Trust subaccount at the death of the Beneficiary are subject to a reimbursement claim by the State for any Medicaid benefits paid on the Beneficiary’s behalf. Upon the death of the beneficiary, distribution shall be made to the following individuals or other entities:
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Initials of Grantor
H.
Name of Distributee
Amount of Trust Estate to be Distributed
_____
Corporation of Guardianship, Inc.
100%
_____
Medicaid
In its discretion, Corporation of Guardianship, Inc. may elect to repay Medicaid an amount up to the total amount of medical assistance paid on behalf of the Beneficiary, but only to the extent that those funds are not retained by the Corporation of Guardianship, Inc.
_____
Corporation of Guardianship, Inc.
If Corporation of Guardianship, Inc. elects to repay Medicaid, it may first retain a percentage (20-60%) of the surplus trust funds, according to a fiveyear sliding scale.
_____
Beneficiaries of the Residuary Estate of Trust Beneficiary as named in his/her Will
All remaining funds after retention by Corporation of Guardianship, Inc. and reimbursement of Medicaid.
Fees: Grantor agrees to pay the fees in accordance with the Schedule that is attached to this agreement as Schedule A and that may be amended from time to time.
I.
Acknowledgment By Grantor: Each Grantor acknowledges that he or she has been advised to have The Corporation of Guardianship, Inc. Umbrella Pooled Trust reviewed by his or her own attorney prior to the execution of this Joinder Agreement and that he or she has reviewed and understands to his or her full satisfaction the legal, economic and tax effects of these instruments. Each Grantor acknowledges that the Trustee is a financial institution and is not licensed or skilled in the field of social services. Grantors acknowledge and agree that the Trustee may conclusively rely upon the Primary Representative or Beneficiary to identify and apply to programs that may be of social, financial, developmental or other assistance to Beneficiaries. The Trustee, its agents and employees, as well as their agents’ and employees’ heirs and legal and personal representatives, shall not in any event be liable to any Grantor or Beneficiary or any other party for its acts as Trustee so long as the Trustee acts reasonably and in good faith. Each Grantor recognizes and acknowledges the uncertainty and changing nature of the guidelines, laws, and regulations pertaining to governmental benefits and each Grantor agrees that the Trustee will not in any event be liable for any loss of benefits as long as the Trustee acts in good faith. Page 3 of 6
Each Grantor acknowledges and agrees that the Trustee, its agents and employees, as well as their agents’ and employees’ heirs and legal and personal representatives, shall not in any event be liable to any Grantor or Beneficiary or any other party for its acts as Trustee so long as the Trustee acts reasonably and in good faith. Each Grantor acknowledges that upon execution of the Joinder Agreement by Grantor and the Trustee, and the funding of a Sub-Account for a Beneficiary, that this Trust, as to the Grantor and the Beneficiary, is irrevocable. Each Grantor acknowledges that after the funding of a Sub-Account, the Grantor shall have no further interest in and does thereby relinquish and release all rights in, control over, and all incidents of interest of any kind or nature in and to the contributed assets and all income thereon. Each Grantor represents, warrants and agrees that he or she has not been provided, nor is he or she relying upon, any representation of or any legal advice by The Corporation of Guardianship, Inc., its agents or employees, in deciding to execute this Joinder Agreement.
IN WITNESS WHEREOF, the undersigned Grantor has reviewed and signed this Joinder Agreement, understands it and agrees to be bound by its terms, and the Trustee has accepted this Joinder Agreement, parties hereby execute this Joinder Agreement to be effective as of this _____ day of ___________________, 2012.
ACKNOWLEDGMENT BY GRANTOR
By: , Grantor
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STATE OF NORTH CAROLINA COUNTY OF GUILFORD On ______________ ____, 2012, personally appeared before me, _____________________, Grantor, with whom I am personally acquainted or who proved to me on satisfactory evidence to be the person who executed the foregoing instrument, and who acknowledged that he/she executed the same as his/her free act and deed.
______________________________________________ Official Signature of Notary (Official Seal) ______________________________________________ Printed/Typed Name
My Commission Expires: _________________________
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ACCEPTANCE BY TRUSTEE The Corporation of Guardianship, Inc., as Trustee
By: Jerry Hollingsworth, President
---------------------------------------------------------------------------------------------------------------------
STATE OF NORTH CAROLINA COUNTY OF GUILFORD On ___________ _____, 2012, personally appeared before me, JERRY HOLLINGSWORTH, who acknowledged he is the President of the maker, The Corporation of Guardianship, Inc., and is authorized by the maker to execute this instrument.
______________________________________________ Official Signature of Notary (Official Seal) ______________________________________________ Printed/Typed Name
My Commission Expires: _________________________
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