Qualified Income Trust - DOC

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					                         Irrevocable Qualified Income Trust
                                  for the Benefit of
                                       [client]
        This Trust Agreement is made this [day]th day of [month], 2008, by [District Name]
Tennessee Public Guardianship Program, by its agent, [Public Guardian’s Name],
Conservator for [client], hereinafter referred to as “Grantor,” and [District Name] Tennessee
Public Guardianship Program, by its agent, [Public Guardian’s Name], hereinafter
referred to as the “Trustee,” for the benefit of [client]. “[District Name] Tennessee Public
Guardianship Program” refers to the [District Name] Tennessee Development District, Public
Guardianship for the Elderly Program, a program established by the Tennessee General
Assembly to assist older Tennesseans, under the provisions found at T.C.A. '' 34-7-101, et.
seq.

       This is an irrevocable Qualified Income Trust (also known as a “Miller Trust”) created
pursuant to 42 U.S.C. §1396p(d)(4)(B) and applicable Tennessee law and policies. The Trust
shall be known as the “Irrevocable Qualified Income Trust for the Benefit of [client]”
(“Trust”).

                                        ARTICLE I
                                      TRUST PURPOSE

        The purpose of this Trust is to assist [client] to qualify for Medical Assistance
(“Medicaid”), to receive necessary nursing facility care or Home and Community Based
Services (“HCBS”). Grantor’s Conservator understands that [client] must meet the eligibility
criteria under Tennessee’s standards, including the standards applicable to Qualified Income
Trusts. In the administration of the Trust, the Trustee shall perform all acts necessary to
establish and maintain [client]’s eligibility for Medicaid, and to comply with Tennessee’s
applicable standards for valid trusts.

                                        ARTICLE II
                                      TRUST FUNDING

        [Client] hereby undertakes to convey and to transfer to the Trustee either (i) her entire
Social Security, pension, and any other monthly income she may receive, or (ii) so much of her
income as shall in any month exceed the prevailing Tennessee Medicaid Income Cap. (The
Grantor’s entire income presently consists of the payments set forth on Schedule “A”, annexed
hereto.) No property other than the [client]’s monthly income (and the earnings thereon) shall
be used to fund this Trust.

         Such payments made into the Trust from the Grantor’s income shall constitute the Trust
fund. The Trustee shall maintain all the trust funds on deposit in a federally insured banking
institution in a separate account in the name of “Southwest Tennessee Public Guardianship
Program, Trustee of the Irrevocable Qualified Income Trust for the benefit of [client],” or
words to that effect.

                                 ARTICLE III
                  DISTRIBUTIONS DURING GRANTOR’S LIFETIME
        During the Grantor’s lifetime, the Trust fund shall be held, disposed of, and
administered by the Trustee in the above-described account for the Grantor so that income
placed in the Trust each month is disbursed or held by the Trustee and used to pay the
Grantor’s approved expenses in accordance with Federal law and Tennessee law, whether from
the Trust or from a combination of the Trust funds and Grantor’s other income not transferred
to the Trust (as provided in Article II). No expenditure shall be made from the trust except in
accordance with the following approved expenditures:

       (1)     A sum equal to the “Personal Needs Allowance” for the benefit of the Grantor
               as established by the State of Tennessee from time to time;

       (2)     Necessary and appropriate medical and remedial expenses not subject to
               third-party payment (“Item D” expenses);

       (3)     A sum for payment of health insurance premiums, including any applicable
               Medicare premiums;

       (4)     A sum up to $20 to pay for expenses necessary for managing the Trust (e.g.,
               bank charges); and

       (5)     Payments to the Grantor’s nursing home or other facility for the Grantor’s
               contribution to the cost of care (“Patient Liability Amount”).

       No other disbursement may be made by the Trustee unless a finding of hardship has
been made by the Tennessee Department of Human Services, and disbursement is expressly
authorized by the Department.

       Any funds remaining in the account each month after the above payments shall be held
by the Trustee and distributed as provided in Article VII below.


                                        ARTICLE IV
                                     IRREVOCABILITY

        The Trust shall be irrevocable. This Trust may not be revoked, modified or amended,
in whole or in part, by the Grantor at any time. The Trustee, acting alone, or a court of
competent jurisdiction, shall have the continuing right and jurisdiction to modify any provision
of this Trust for the purpose of conforming the provisions thereof to prevailing law and to
maintain the eligibility of [client] for Medicaid medical assistance or other public benefits,
taking into consideration the effective date of any such law and the date of the establishment of
this Trust.

                                ARTICLE V
             APPOINTMENT OF TRUSTEES, RESIGNATION OR REMOVAL

       A.      Resignation or Discharge of Trustee.


                                              -2-
       (1)     Any Trustee may resign by giving thirty (30) days written notice to the Grantor
               and to each beneficiary, including the Bureau of TennCare. Notice to the
               Bureau shall be accomplished by a written notification to the Tennessee
               Department of Human Services, or by any other notification mechanism
               established by the Bureau of TennCare. Such resignation shall be effective
               thirty (30) days from the date such notice is given.

       (2)     Any Trustee shall be automatically and forthwith discharged and removed from
               authority and duties of a fiduciary or trustee hereunder, should he or she fail to
               have the capacity to competently act as a trustee. Such lack of capacity shall be
               established if any substitute Trustee nominated hereunder shall receive a written
               determination by the Southwest Tennessee Public Guardianship Program can no
               longer serve the Grantor due to (1) the elimination of funding for the services
               provided to the Grantor; (2) the elimination of the Public Guardianship
               Program; (3) the assumption of Public Guardianship duties by another agency
               pursuant to state law and regulations; or (4) the Grantor’s ineligibility for
               continued services through this program, based on the order of the Chancery
               Court of Hardin County, Tennessee.

       B.      Appointment of Successor Trustees. Upon the resignation of the initial
Trustee, the initial Trustee may appoint a successor trustee. Such appointment shall be
accomplished by a written document, duly witnessed or notarized and attached to the Trust
Agreement. Additionally, a Successor Trustee may be appointed by the order of the Chancery
Court of [County] County, Tennessee. Upon the appointment of a Successor Trustee, the
successor named in this instrument shall automatically assume the powers of Trustee
hereunder. In the event that the Grantor has no conservator in place, then any interested person
may petition the court for the appointment of a Successor Trustee.

                                     ARTICLE VI
                            TRUSTEE’S POWERS AND DUTIES

        A.      The Trustee shall have all the powers and privileges granted trustees by the laws
of the State of Tennessee, as limited by the restrictions relating to the purpose of this trust. The
right to pay principal or income from the Trust for the benefit of the Grantor shall be
exclusively vested in the then-serving Trustee or successor Trustee. However, any power
which would cause this Trust to lose qualification as a Qualified Income Trust shall not be
exercisable by any Trustee hereunder.

        B.      Any Successor Trustee shall have all rights, powers, duties and discretion
conferred or imposed upon the original Trustee. No Successor Trustee shall be obliged to
examine the accounts and actions of any previous Trustee, except as required by the laws and
regulations relating to the Public Guardianship Program of Tennessee. No Trustee shall be
liable for any act or omission unless the same be due to such Trustee’s criminal or fraudulent
intent.

      C.      Any successor Trustee shall become responsible for the applicable Trust Estate
only when, as and if the same shall be received by said Successor Trustee and, in determining


                                               -3-
such estate, such Successor Trustee shall only be responsible to make a reasonable inquiry
from the records of the prior Trustee which are available.

        D.      In the event of a change in relevant federal or state laws, rules or policies
concerning irrevocable income trusts, then the Trustee is instructed to administer and distribute
the trust assets and income, including the Beneficiary’s monthly contributions, according to
such revised laws, rules and policies, consistent with the Grantor’s intent, appropriately
modifying this Trust, if necessary.

       E.     Modification of Trust Agreement. In the event this instrument is determined
to be non-compliant with legal requirements for a Qualified Income Trust under federal or
Tennessee laws or regulations, the Trustee, in the Trustee’s sole discretion, is authorized to
formally amend the Trust document to effectuate its purpose and prevent the Beneficiary from
being denied Medicaid services.

        F.      Annual Accounting. The Trustee shall be required to submit an annual
accounting to the Tennessee Department of Human Services or its designee, in a form
agreeable to the Department of Human Services, of all income placed in the Trust, all funds
distributed, the purpose for the distribution, and the total amount of funds remaining.

       G.     In the event of a change of Trustee or any modification to the terms of the Trust,
the Trustee shall promptly notify the Tennessee Department of Human Services of such
changes.

                                        ARTICLE VII
                                       TERMINATION

         The Trust shall cease and terminate upon the death of the Grantor, or earlier if the
Trustee determines that the existence of the Trust is no longer necessary to establish Medicaid
eligibility for the Grantor, or if nursing facility care or HCBS is no longer medically necessary
for or no longer being received by the Grantor. Upon the termination of the Trust, the Trust
property shall be distributed as follows:

        A.    To the State of Tennessee, Bureau of TennCare, in an amount equal to the total
Medical Assistance paid on behalf of the Grantor by the State Plan for Medical Assistance or
other approved waiver programs, up to the total Trust account balance.

       B.      Any remainder after the State of Tennessee’s claim has been paid, to the
Grantor’s designees or the heirs at law.


                                     ARTICLE VIII
                                  GENERAL PROVISIONS

        A.      Governing Law. The construction of this Agreement and the validity of the
interest created hereby shall be governed by the laws of the State of Tennessee and applicable
federal law and the rules and regulations thereunder. The administration of the Trust shall be


                                              -4-
governed by the laws of the State of Tennessee, or by the laws of any other state in which the
Trust may from time to time be administered.

         B.     Spendthrift/No Assignment. No beneficiary shall have any right to anticipate,
sell, assign, mortgage, pledge or otherwise dispose of or encumber all or any part of the Trust
Estate, nor shall any part of the Trust Estate, including income, be liable for the debts or
obligations, including alimony, of any beneficiary or be subject to attachment, garnishment,
execution, creditor’s bill or any other legal or equitable process. This provision shall not bar
any remedy sought by the State of Tennessee or other state jurisdictions for the purpose of
obtaining trust distributions in accordance with this Trust declaration and applicable federal or
state laws and administrative regulations.

        The paragraph and article headings used herein are for convenience only and shall not
be resorted to for interpretation of the Trust. Wherever the context so requires, the masculine
gender shall include the feminine gender (and vice versa) and the singular shall include the
plural (and vice versa). Wherever the terms “Grantors,” “Beneficiaries” or “Trustees” (plural)
are noted they shall also mean “Grantor” “Beneficiary” or “Trustee” (singular), as the case may
be, and vice versa, unless the context would preclude such interpretation. If any portion of this
Trust is held to be void or unenforceable, the balance of this Trust shall nevertheless be carried
into effect.


        IN WITNESS WHEREOF, this Trust Agreement is executed by [District Name]
Tennessee Public Guardianship Program, by its agent, [Public Guardian Name],
Conservator for the Grantor, as and for the act of [client], the Grantor, and [District Name]
Tennessee Public Guardianship Program, by its agent, [Public Guardian Name], Trustee,
as of the date first above written.



                                              ________________________________________
                                              [client], Grantor, by
                                              [District Name] Tennessee Public Guardianship
                                              Program, Conservator, by its agent, [Public
                                              Guardian Name]



                                              ________________________________________
                                              [District   Name]      Tennessee      Public
                                              Guardianship Program, Trustee, by its agent,
                                              [Public Guardian Name]




                                              -5-
STATE OF TENNESSEE
COUNTY OF [County]

         Personally appeared before me, _____________________, a Notary Public in and for said State
and County, [Public Guardian Name], agent for the [District Name] Tennessee Public
Guardianship Program, with whom I am personally acquainted (or proved to me on the basis of
satisfactory evidence), and who acknowledged that such person executed the within instrument for the
purposes therein contained, and who further acknowledged that such program is the Conservator of
[client], the Grantor of the foregoing Trust and is authorized by said Grantor to execute this instrument
on the Grantor’s behalf.

        WITNESS my hand and Notarial Seal at office, this [day]th day of [month], 2008.


                                                 ____________________________________________
                                                 NOTARY PUBLIC

My Commission Expires:
_____________________




STATE OF TENNESSEE
COUNTY OF [County]

        Personally appeared before me, ________________________, a Notary Public in and for said
State and County, [Public Guardian Name], agent for the [District Name] Tennessee Public
Guardianship Program, Trustee, to me known (or proved to me on the basis of satisfactory evidence)
to be the person described in and who executed the foregoing instrument and acknowledged that she
executed the same for the purposes therein contained.

        WITNESS my hand and Notarial Seal at office, this [day]th day of [month], 2008.


                                                 ____________________________________________
                                                 NOTARY PUBLIC

My Commission Expires:
_____________________




                                                  -6-
                            SCHEDULE A
          Minimum Monthly Income of Grantor Transferred into the
                   Qualified Income Trust Account
(Minimum amount may vary depending upon actual amount received monthly, due to changes
in cost of living adjustments, Medicare premiums and other adjustments. Additional amounts
may be deposited into the account as needed.)



           Source                                                  Amount

           Social Security

           Pension

           Other

                                     Total:




Location of Trust Bank Account:

Bank: ________________________________________

Account No. _______________________

Initial Deposit Amount: $___________________

Initial Deposit Dated: ____________________




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