Petition For Authorization To Act To Establish Pooled Trust Page 2
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35. That the AGED Pooled Trust agrees to submit to the jurisdiction of the Court in this
matter.
WHEREFORE, the Petitioner, (GUARDIAN’S NAME), as Guardian of the person and
property of (BENEFICIARY’S NAME), Incapacitated, respectfully prays this Court
enter an Order authorizing Guardian to execute the AGED Pooled Trust joinder
agreement, and such other instruments to establish an AGED Pooled Trust account for
the benefit of the Ward, and transfer a sufficient amount of the Ward’s assets in the
AGED Pooled Trust to enable the Ward to become financially eligible for Medicaid.
Under penalties of perjury, I declare that I have read the foregoing, and the facts
alleged are true, to the best of my knowledge and belief.
Executed this ________ day of ___________________, 2016.
______________________________
(ATTORNEY INFORMATION)
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