Qualified Income Trust Declaration Form printable pdf download

QUALIFIED INCOME TRUST

This

declaration

trust

made

this

_____

day of

_________,

20__,

______________________ (Settlor-name of person establishing the Trust), is to be known

as the _____________________ (name of the Primary Beneficiary) Qualified Income Trust,

and is to be governed by the terms set forth below.

Article I

Trust Purpose. This is an irrevocable Qualified Income Trust, sometimes referred to as a

“Miller Trust”, and is authorized by 42 U.S.C. §1396p(d)(4)(B). The purpose of this Trust

is to enable the Primary Beneficiary to qualify for medical assistance ("Medicaid"). The

Primary Beneficiary of the trust is ________________________.

Article II

Trust Funding. The property to be placed in the Trust is monthly income received by the

Primary Beneficiary including income from the following source(s):

1. _______________________________

2. _______________________________

3. _______________________________

4. _______________________________

No property other than the Primary Beneficiary’s income may be placed in the Trust. Income

must be deposited into the trust account during the same month in which the income is

received by the Primary Beneficiary.

Article III

Trust Distributions. No expenditures shall be made from the Trust except in accordance with

this paragraph. The trustee shall make distributions from the trust only in amount and for the

purposes necessary to maintain income eligibility of the Primary Beneficiary for Medicaid.

Consistent with the requirements of the Medicaid program that require all income including

any income that is not placed in the Trust be used for post eligibility expenses, the Trustee

shall make payments from the Trust in the following priority, no later than the last day of the

calendar month in which the income is received by the Trust:

1. A monthly personal or maintenance needs allowance for the Primary Beneficiary;

2. A maintenance allowance for the spouse, if any, of the Primary Beneficiary and, if

applicable, a maintenance allowance for family dependents;

3. Incurred medical expenses of the Primary Beneficiary. In accordance with rule

5160:1-3-04.3 of the Administrative Code, when income is used to help pay for long

Qualified Income Trust Declaration Form