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Table of Contents Section Section Title Page

1.Definitions 1

2.Trust Established by 1

3.Beneficiary/Grantor 1

4.Parent/Grandparent 2

5.Attorney In Fact 2

6.Guardian 2

7.Court Order 2

8.Contribution to Trust 3

9.Beneficiary Advocate 4

10. Beneficiary’s Impairment or Disability 4

11. Beneficiary’s Current Benefits 5

12. Distribution of Remainder Upon Termination of Beneficiary’s IBA 7

13. Amendments to Joinder Agreement 10

14. Taxes 10

15. Final Remainder Beneficiaries 10

16. Money Managers 10

17. Trustee Fees and Charges 11

18. Disbursements from the Individual Benefit Account 11

19. Acknowledgments 11

20. Addendum or Addenda Attached 12

21. Representations of the Parties 12

22. Miscellaneous 12

23. Effective Date 13 Appendix A - Definitions 15 ADVOCATES & GUARDIANS FOR THE ELDERLY & DISABLED, Inc.



Trust IBA No. Acceptance Date:___________,20_______ Amendment Filed:  Yes  No


–  –  –

By this Joinder Agreement, on the day of, 20 the undersigned hereby enrolls in and adopts the Master Trust indicated below, a copy of which has

been received and incorporated herein by reference and hereinafter referred to as the “Trust”:

Please answer all questions in this Joinder Agreement. If a question does not apply, insert “N/A” as your answer. Also please place a checkmark in all applicable boxes.

1. Definitions The definitions of the terms used in this Joinder Agreement are located in the Appendix.

2. Trust Established by:

 Disabled Individual (Beneficiary/Grantor)  Attorney-in-Fact  Parent  Grandparent  Guardian  Court

3. Beneficiary/Grantor:

–  –  –

(If answer is Yes, the Trust must be established by a Statutory Representative, Attorney-in-Fact under a valid power of attorney, Guardian (with Letters of Guardianship) or Court Order.)

–  –  –

 Income Contribution: If the Grantor intends to use this trust to reduce the beneficiary’s income for purposes of qualifying for one or more Medicaid program, please provide the gross

monthly income from all sources of income:

–  –  –

Relationship:  Beneficiary/Grantor  Parent  Grandparent  Guardian  Attorney-in-Fact  Other Person _________________________________________



–  –  –

Successor Beneficiary Advocate:

Relationship:  Beneficiary/Grantor  Parent  Grandparent  Guardian  Attorney-in-Fact  Other Person _________________________________________



–  –  –

(If no Beneficiary Advocate is named or able to serve, AGED and/or the Trustee may select and appoint a Successor Beneficiary Advocate. However, if a Trust Beneficiary becomes incapacitated and a guardian is appointed, the guardian will be given preference as the Beneficiary Advocate.)

10. Beneficiary’s Impairment or Disability Nature of impairment or disability:  Total and Permanent  Unable to work (Describe)

Date Incurred:



Estimated Length of Time:

Special Requirements:

–  –  –

a. Termination after the Death of a Beneficiary. Upon the death of a Trust Beneficiary, verified by a copy of the deceased Beneficiary’s death certificate, any amounts that will remain in a

deceased Beneficiary’s IBA shall be distributed under one of the following options:

 One hundred percent (100%) shall be retained by the Trust as surplus Trust property and administered and distributed by the Trustee in its sole and absolute discretion in accord with the following provisions.

a) for the direct or indirect benefit of other Beneficiaries;

b) to add disabled persons, as defined in 42 U.S.C. §1382c(a)(3) to the Trust as Beneficiaries;

c) to provide disabled persons, as defined in 42 U.S. C. §1382c(a)(3), with equipment, medication, education or other services deemed suitable for such persons by the Trustee;

d) to provide disabled persons, as defined in 42 U.S. C. §1382c(a)(3) with professional guardianship services.

 _____ % (Minimum of Ten Percent (10%)) shall be retained by the Trust as surplus Trust property and administered and distributed and distributed by the Trustee in its sole and

absolute discretion in accord with the following provisions:

e) for the direct or indirect benefit of other Beneficiaries.

f) to add disabled persons, as defined in 42 U.S.C. §1382c(a)(3) to the Trust as Beneficiaries;

g) to provide disabled persons, as defined in 42 U.S. C. §1382c(a)(3), with equipment, medication, education or other services deemed suitable for such persons by the Trustee;

h) to provide disabled persons, as defined in 42 U.S. C. §1382c(a)(3) with professional guardianship services.

Any assets not retained as surplus Trust property shall, after payments as provided in paragraph

12.b., below, which are made pursuant to Article 6.2(c) and (d) of the Master Trust, be distributed to the Final Remainder Beneficiaries named in paragraph 12.c., below.

Pooled Special Needs Trust ©AGED Revision Date: 06/20/12 Joinder Agreement Page: 6 b. Government Reimbursement Claims. To the extent that Trust assets are not being retained by the Trust as surplus Trust property, the Trustee may pay administrative expenses to include taxes due from the trust to the State(s) or Federal government because of the death of the beneficiary and reasonable fees for administration of the trust estate such as an accounting of the trust to a court, completion and filing of documents, or other required actions associated with termination and wrapping up of the trust. Administrative expenses shall not include taxes due from the estate of the beneficiary other than those arising from inclusion of the trust in the estate;

Inheritance taxes due for residual beneficiaries; Payment of debts owed to third parties; Funeral expenses; and Payments to residual beneficiaries. Thereafter, the Trustee shall distribute such remaining Trust property to each state in which the Beneficiary received government assistance, based on each state's proportionate share of the total government assistance paid by all of the states on the Beneficiary's behalf and up to the amount of that assistance. The Beneficiary Advocate shall be responsible for determining the amount of such state reimbursement claims (payback amount). This repayment to the states shall be given all priority over any other expenses to the degree enumerated in the statutes and government rules. In the absence of federal regulations directing the Trust as to priority in the case of multiple state claims, the claims of multiple states shall be prorated and paid to the extent funds are retained as surplus Trust property. The Trustee is authorized to rely on statements of claims provided by the Beneficiary Advocate that have been received from the applicable state Medicaid agency. The Payback Amount shall only be for medical assistance paid on behalf of the Trust Beneficiary during the aforesaid Payback time period. Notwithstanding anything to the contrary herein, if the government reimbursement claims equal or exceed the IBA Remainder Amount, the IBA Remainder Amount in its entirety shall be deemed surplus Trust property and shall be retained by the Trust.

–  –  –

 Not Applicable – 100% Retention by Trust was selected above.

 Named Individuals as follows: (Note: The total of all distribution percentages must equal %100)

–  –  –

 If the Trustee is required to locate Final Remainder Beneficiaries, Grantor agrees that the Trustee may recover its reasonable costs and expenses associated with locating Final Remainder Beneficiaries. If the Trustee is unable to locate any Final Remainder Beneficiary within a reasonable time and after diligent search, he or she shall be deemed to have predeceased the Grantor and the entire remaining amount shall be retained by the Trust.

 A Final Beneficiary or Beneficiaries should seek advice about the tax, and any applicable Government Assistance program ramifications of any particular distribution before a distribution is made from the amounts retained in the Trust Beneficiary’s IBA.

13. Amendments to Joinder Agreement The provisions of this Joinder Agreement are not subject to amendment by the Payor, the Beneficiary/Grantor and/or the Beneficiary Advocate. The Trustee, however, may from time to time amend this Joinder Agreement upon 30 days written notice to the Payor, the Beneficiary/ Grantor and/or the Beneficiary Advocate, as may be applicable for the purpose of the administration and construction of the provisions of the Joinder Agreement and to comply with state and federal law. An amendment made for the purpose of complying with a state law and/or requirements of a specific government agency may be accomplished by a formal amendment or by an addendum to the Joinder Agreement. There may be some states, however, in which the Trust will not be able to be used because of the laws of that state or the requirements of a government agency in that state.

14. Taxes

The Trustee has made no representation as to the estate, gift or income tax consequences affecting funds contributed or gifted to the Trust. The Trustee has, however, been advised that each IBA may be treated as an individual grantor trust for income tax purposes. Independent legal and professional tax advice is, therefore, recommended.

15. Final Remainder Beneficiaries

The Final Remainder Beneficiaries shall be as set forth in Section 12(c) above. Notwithstanding the foregoing, the Final Remainder Beneficiaries will only be entitled to a distribution from the Beneficiary’s IBA after all amounts have been paid to or for the Trust, Trust expenses and Government Reimbursement Claims, if any.

16. Money Managers The Trustee in its sole discretion may recruit, select, engage, terminate, and change one or more money managers without the consent of the Trust Beneficiary and/or Beneficiary Advocate.

–  –  –

The Trust Beneficiary agrees to pay those fees and charges each month for the administration of Trust Beneficiary’s IBA (and other charges that may be required from time to time) in accordance with the attached Trust Fee Agreement between AGED and the Trust Beneficiary or on behalf of the Trust Beneficiary. The Trustee is authorized to pay such fees and expenses from the Trust Beneficiary's IBA to AGED and itself.

18. Disbursements from the Individual Benefit Account

The IBA will be managed and administered for the sole benefit of each Trust Beneficiary, but the investments of the IBA may, in the sole discretion of AGED and the trustee, be pooled with other Trust IBA’s. Disbursements for any non-support items for the benefit of the Beneficiary may be made when a Beneficiary Advocate believes such supplemental needs are not being provided by any public or government agency, or are not otherwise being provided from any other source available to the Beneficiary, but subject to the discretion of the Trustee. The Grantor recognizes that disbursements are discretionary by the Trustee. With this in mind, the Grantor expresses the following desires as to how funds in a Beneficiary’s Trust IBA might be


 None  Supplemental Services as described in the Trust.

 Specific Supplemental Services Requested below:

–  –  –

The Grantor/Beneficiary, individually, and on behalf of the Beneficiary (the “Parties”)

acknowledge and agree that:

a) They have received copies of the Master Trust and this Joinder Agreement, and have been advised to have these documents reviewed by an independent attorney representing Grantor/Beneficiary’s best interests.

–  –  –

d) The Parties acknowledge and agree that A.G.E.D, the Trustee, its officers, directors, advisory council, employees, agents and their heirs, legal representatives, successors and assigns (hereinafter referred to as “Qualified Persons”) shall not in any event be liable to the Parties or any other person for their acts as long as their acts are reasonable and made in good faith.

e) The Parties acknowledge that upon execution of this Joinder Agreement by the Parties and the funding of the IBA for the Trust Beneficiary, the contribution is irrevocable. The Parties further acknowledge that after the funding of an IBA, they shall have no further interest in and do thereby relinquish and release all rights in, to, control over, and all incidents of ownership and interest of any kind or nature in and to the contributed assets and all income thereon.

–  –  –

21. Representations of the Parties

The Parties represent, warrant and agree that:

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