Irrevocable Funeral Trust Agreement Template (For State And Federal Entitlement Programs Only)
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1CPN-8, #11-02
IRREVOCABLE FUNERAL
TRUST AGREEMENT
(For State and Federal Entitlement Programs Only)
This is to certify that ________________________________________________________________________,
(Beneficiary)
SS# ________________________, has received, applied for, or intends to apply to be an aged, blind or disabled
recipient of benefits pursuant to the Federal Supplementary Security Income Program under Title XVI of the
Social Security Act or other federal or state entitlement programs.
It is hereby agreed by the undersigned parties and understood and acknowledged by said beneficiary or grantor
that:
1. The money paid to the undersigned funeral home, intended to pay for funeral arrangements of the
beneficiary pursuant
to
a
prearranged
funeral
agreement,
contract
or
plan
dated
___________________, 20 _____ and deposited by said funeral home (as agent) in a Kentucky
bank, savings and loan, or credit union (Bank) as Trustee constitutes an irrevocable trust fund
during the lifetime of the beneficiary. This irrevocable funeral trust agreement forms a part of the
said prearranged funeral agreement, contract or plan.
2. If for any reason the beneficiary or grantor fails to apply for entitlement benefits within thirty (30)
days from the signing of this Agreement, fails to receive, or otherwise becomes ineligible for
entitlement benefits, then this trust shall be a revocable trust.
3. The irrevocable trust established pursuant to this agreement shall not affect the selection of
funeral goods or services or the selection of the funeral home. At any time the beneficiary or
grantor of this irrevocable trust may, by written request to the funeral home (as agent) and trustee
(Bank), change the funeral home, trustee or both.
4. By signing this Agreement, the beneficiary or grantor gives authorization to the funeral home and
the Attorney General, Commonwealth of Kentucky, to access the appropriate records to ensure
compliance with KRS Chapter 367.
MEANING OF
Signed: ________________________________________________
IRREVOCABILITY
BENEFICIARY OR GRANTOR
The Acceptance of this
Agreement creates an
________________________________________________________
IRREVOCABLE TRUST
Name of Funeral Home
which means that except as
provided in Paragraph 2, any
refund, withdrawal or other
____________________________ ,
___________
Kentucky
disposition of the deposits on
City
Zip Code
account plus accrued
interest, for any purpose, will
By: _____________________________________________________
be and must be refused by
the Funeral Director, The
(Authorized Representative of Funeral Home)
Trustees, the Trust Fund,
and any Officer, Employee
________________________________________________________
or Agent.
Date
THIS FORM MUST BE MAINTAINED IN THE FILES OF THE FUNERAL HOME AS AGENT
This form is approved by the OAG pursuant to KRS Chapter 367. Changes in federal law may affect this Agreement.
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