Irrevocable Joinder Agreement
IRREVOCABLE JOINDER AGREEMENT
This is a legal document. You are encouraged to seek independent, professional advice before signing.
The undersigned hereby enrolls in and adopts the Declaration of Trust of the Hope Network Foundation dated August 9, 1999, which is incorporated herein by reference.
Source of Initial Funds: ______
Lawsuit, Social Security, Inheritance, Savings of Individual, Other
AMOUNT OF INITIAL DEPOSIT: $______
A. Grantor’s name and address and telephone, (guardian, individual, parent):
B. Beneficiary - (person with disability):
Name: ______
Date of Birth: ______
Social Security # ______
C. Nature of Disability: ______
D. Name and address and phone number of person who should receive official correspondence from the Trust. Please state if they are guardian, parent, social worker or other key person.
Name:______
Address:______Phone______
Email ______
E. Supplemental Security Income: ______/month.
F. Social Security Disability: ______
G. Employment______
H. Medicaid Case number:______
I. List all other forms of government assistance that the Beneficiary receives:
______
J. Private health insurance address, policy number: ______
K. Location of prepaid funeral or burial insurance:______
L. Distributions upon the Beneficiary’s death: if, upon the Beneficiary’s death, funds
remain in his or her separate Trust sub-account, such funds shall be deemed to be surplus Trust property and shall be retained by the Trust and, in the Trustee’s sole discretion, used (a) for the benefit of other Beneficiaries of the Trust, (b) to aid persons who are indigent and disabled, as defined in 42 U.S.C. sec. 1382c (a) (3), or (c) to provide persons who are indigent and disabled, as defined in 42 U.S.C. sec. 1382c (a) (3), with housing or supplemental support services deemed suitable for such persons by the Trustee. To the extent that any amounts remaining in the Beneficiary’s account upon the death of the Beneficiary are not so retained by the Trust, as required under 42 U.S.C. §1396p (d) (4) (C), or any regulations promulgated thereunder, or the corresponding provisions of any subsequent Federal law, the Trustee shall pay from such remaining amounts in the account to any state an amount equal to the total amount of medical assistance paid on behalf of the Beneficiary under the State’s plan under 42 U.S.C. §1396 (a) et seq. Gifts or devises to the Trust shall be similarly treated unless the purpose for which the gift is made is specified by the donor.
M. Uses for which Trust sub-account distributions may be made: Supplemental Care.
N. The supplemental needs plan established for the Beneficiary shall be incorporated by reference in this Joinder Agreement.
O. The Trust sub-account will be administered for the sole benefit of the Beneficiary during his or her lifetime.
P. The Grantor recognizes that all distributions are at the Trustee’s sole discretion. With this in mind, the Grantor(s) expresses the following desires as to how funds in the Trust sub-account might be used: ______
Q. Trustee fees will be charged in accordance with reasonable costs incurred by
Trustee.
The provisions of this Joinder Agreement may be amended by the Grantor(s),so long as any such amendment is consistent with the Declaration of Trust,and the then applicable law.
R. The Grantor acknowledges that the Hope Network Foundation hasmade no
representation to the Grantor that contributions to the Trust are deductible as
charitable gifts.
S. Trust sub-account income, whether paid in cash or distributed in other property, may
be taxable to the Beneficiary subject to applicable exemptions and deductions.
Professional tax advice isrecommended.
T. Trust sub-account income may be taxable to the Trust, and when this is the case, such
taxes shall be payable from the Trust sub-account.
U. The Trust administered by the Hope Network Foundation is a pooled accounts trust,
governed by the laws of the State of Michigan, in conformity with the provisions of 42
U.S.C. § 1396p(d)(4)C, amended August 10, 1993, by the Revenue Reconciliation Act
of 1993. To the extent there is conflict between the terms of this Trust and the
governing law as from time to time amended, the law and regulations shall control.
V. Disclosure and Waiver of Potential Conflicts of Interest:
Individuals executing the Joinder Agreement are aware of the following potential conflicts of interest that are connected with Trustee’s administration of the Trust:
The Trustee may appoint persons to assist in the carryingout of its Trustee duties who are associated with the HopeNetwork Foundation or Hope Network, such as staff, boardmembers, volunteers, etc. Additionally, the Hope Network
Foundation or Hope Network may provide services and supports to individual sub-account Beneficiaries.
The Trustee may appoint a law office, or other qualified service agency to act as its agent to assist in the carrying out of its Trustee duties, which office may also act as legal counsel for sub-accountGrantors and/or Beneficiaries.
The Trustee is the remainder beneficiary of the sub-accountscreated hereunder.
IN WITNESS WHEREOF, the undersigned Grantor(s) has/have reviewed and signed this Joinder Agreement, understand(s)s it, and agree(s) to be bound by its terms, and has accepted and signed this Joinder Agreement this
______day of ______, 20_____.
Grantor:______
Person with disability or parent, or guardian
Witnesses: (1) ______(2) ______
(signature)(signature)
Printed Name: ______
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