Qualified Income Trust Declaration Form (Page 2 of 2) in pdf

term care services or other medical care provided to the individual, the individual is

considered to have received fair market value for the income placed in the trust, up

to the amount actually paid for other medical care provided to the individual and to

the extent that the payments purchased care at fair market value;

4. The Trustee may also make payments from the Trust for bank fees, attorney fees,

and other expenses required to establish and administer the trust in a reasonable

amount up to fifteen dollars per month or as otherwise authorized under Rule

5160:1-6-03.2 of the Ohio Administrative Code.

Article IV

Trustee. The Trustee shall administer this Trust in good faith to effectuate its purpose, and

shall act in accordance with the terms of the Trust and with all applicable laws including, but

not limited to Chapters 5801. to 5811. of the Ohio Revised Code. The initial Trustee

hereunder is __________________ . If the initial Trustee resigns, becomes deceased or is

otherwise unable or unwilling to serve, then __________________ shall serve as successor

Trustee. Any Trustee may, while serving as Trustee, appoint one or more successor trustees.

Article V

No Transfers or Assignments. The Trust’s assets, income and distributions shall not be

anticipated, assigned, transferred or encumbered in any manner. The Primary Beneficiary

shall not have the power to anticipate, assign, transfer or encumber the Primary Beneficiary’s

interest in the Trust, nor shall such interest, while in the possession of the Trustee, be liable

for, or subject to the debts, contracts, obligations, liabilities or torts of the Primary

Beneficiary.

Article VI

Termination. This Trust shall terminate upon the death of the Primary Beneficiary, at which

point the remaining Trust property shall be distributed to the Ohio Department of Medicaid

or its successor up to an amount equal to the total medical assistance paid on behalf of the

Primary Beneficiary; the Trustee is prohibited from repaying other persons or creditors prior

to this distribution. Any remaining Trust property after the Ohio Department of Medicaid

(or

its

successor)’s

claim

has

been

paid

shall

distributed

_________________________.

Signed this

day of

Settlor

Initial Trustee

Qualified Income Trust Declaration Form Page 2