This section describes the financial arrangements that have been made to benefit the individual. Attach the names of any financial advisers and copies of financial documents here. If you have already completed Section A on a form for another life area, you may skip it and go on the Section B. Otherwise, provide information for each item below.

Section A

(1) Name of family member to which this document applies.

(2) Name of person completing this form.

Relationship to the person named (1) above.

He/she needs assistance with:
Banking
Yes
No

Paying bills
Yes
No

Making purchases
Yes
No

Counting money
Yes
No

Recognizing denominations
Yes
No

(If appropriate) I have set up the following, to safeguard that money:
two-signature checking account
durable power of attorney
representative payee
a trust
other (describe)

I have set up a Special Needs Trust:
Yes
No

The following information pertains to that trust.

The future (successor) trustee(s) will be:
Name:
Address:
Phone Number:
Relationship to the person:

Co-successor, Trustee, or Standby (Indicate which below.)
Name:
Address:
Phone Number:
Relationship to the person:
Co-successor
Trustee
Standby

The trustee(s) has discretion over how the money in the trust is to be spent to benefit the individual named above in (1).
Yes
No

The following assets are/will be found in my trust:

As of this date , the value of the trust is:

A copy of this document can be found:
(If possible please attach a copy of the trust document to this form.)

In my will, I have named the following person to be the Administrator (Executor) of my estate, upon my death:
Name:
Address:
Phone Number:

My attorney's information is:
Attorney's Name:
Firm's Name:
Address:
Phone Number:

My family member (named above in #1) has the following Medicaid Number:

It is important that eligibility for government benefits and programs should continue.
It is not important that eligibility for government benefits and programs should continue.

2) Policy Number:
Phone number(s)

The costs are already paid:
Yes
No

Contact the following for full burial information:
Name:
Phone Number:
Address: