Filled In Example Mc-025 Form printable pdf download

Filled In Example Mc-025 Form

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MC-025

CASE NUMBER:

SHORT TITLE:

The Terry Doe Special Needs Trust

PCN-16-123456

ATTACHMENT (Number):

(This Attachment may be used with any Judicial Council form.)

The trust is a Third Party Special Needs Trust.

Trustees

John Doe and Jane Doe

1234 ABC Street

San Francisco, CA 94102

415-123-4567

Beneficiary has a disability and will likely require government assistance during

Grantor's life and after Grantor’s death. The nature of the disability is: Autism and

Mental Retardation.

Grantor creates this special needs trust to enhance Beneficiary's quality of life while

at the same time preserving Beneficiary's eligibility for government support and medical

assistance programs, including SSI, Medicaid, or other similar programs. Grantor intends

this Declaration of Trust to be interpreted in light of this purpose.

The ward has not received any distributions or benefits.

Value: 11,000.32

(If the item that this Attachment concerns is made under penalty of perjury, all statements in this

Page

Attachment are made under penalty of perjury.)

(Add pages as required)

Form Approved for Optional Use

ATTACHMENT

Judicial Council of California

to Judicial Council Form

MC-025 [Rev. July 1, 2009]

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Filled In Example Mc-025 Form