GOLDEN STATE POOLED TRUST Enrollment Form & Data Collection Sheet

REFERRING ATTORNEY (You must have an attorney to enroll for services)

Firm Name:Name:Address:City:State: Zip:

Primary Phone:Fax Number:Email:

Trust enrollment documents will be sent to this email

ESTABLISHED BY INDIVIDUAL

Full Name:Address:City:State: Zip:

Social Security Number:Date of Birth:Primary Phone:Alternate Phone:Email:

ESTABLISHED BY COURT County:Case #:Judge:

Matter of:

FUNDING SOURCE Funding Source:Amount: $Date to be funded:

Comments:

BENEFICIARY

Full Name:Address:City:State: Zip:

Social Security Number:Date of Birth:Primary Phone:Alternate Phone:Email:

DISABILITY Is beneficiary a Minor? •

Yes No

Does the beneficiary have legal capacity? • Yes No

Do you own your home? Yes No

CAPACITY Disability:

Date of Disability:

Do you require special medical equipment? Yes No

If yes, what type:_________________________

Do you require a companion for travel? Yes No

Please attach copies of Beneficiary’s:1. Benefit Eligibility Letters2. Benefit Eligibility Cards3. State Driver’s License4. Social Security Card5. Birth Certificate and/or Passport6. Any other pertinent benefit or identification documentation

Red entry fields are required. If not applicable, please type "N/A".

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BENEFITS Monthly AmountSocial Security Supplemental Security Income (SSI) Social Security Disability Income (SSDI) Medi Cal Medicare Food Stamps OtherIHSS

$$$$$$$

Hours/Month

PENDING BENEFITS Benefit Type: Estimated date:

ADVOCATE Beneficiary themselves Guardian or Conservator POA Professional Advocate

Full Name:Address:City:State: ZipRelationship to Beneficiary:

Social Security Number:Date of Birth:Primary Phone:Alternate Phone:Email:

SUCCESSOR ADVOCATE

Full Name:Address:City:State: ZipRelationship to Beneficiary:

Social Security Number:Date of Birth:Primary Phone:Alternate Phone:Email:

CASE COMMENTS:

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REMAINDER BENEFICIARIES Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

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CONTINGENT BENEFICIARIES Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Distribution Amount:Distribution Percentage: % Social Security Number:Primary Phone:Alternate Phone:Email:

Full Name:Address:City:State: Zip:Relationship to Beneficiary:

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SPENDINGPLAN

Tobefilledoutbythereferringattorney

Context

Inorderforustobetterunderstandthebeneficiary’suniquesituationandneeds,pleasefillouttheattachedSpendingPlan.Thisdocumentallowsustocollecthelpfulinformationaboutrecurringexpensesandanticipatedneeds.

Itisthetrustee’sjobtomanagefunds,makemoneyavailableforapprovedexpenses,andensurethatgovernmentbenefitsstayprotected.Pleasenotethatcertainexpenses,ifpaidforbythetrust,maynegativelyimpactgovernmentbenefitsorevenmakethebeneficiaryineligibletoreceivebenefits.

ThetrusteewillreviewthisSpendingPlanandmaychoosetodiscussitfurtherwiththereferringattorney,beneficiary,oradvocate.Alldisbursementswillbemadeatthediscretionofthetrustee.

Instructionsforthereferringattorney

PleasecompletethefullSpendingPlanwiththebeneficiaryand/orbeneficiaryadvocateandreturnittotheGoldenStatePooledTrustatshelley@gspt.org.Ifyouhaveanyquestions,youmaycontactShelleySunseriat(877)336-3096.

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Spendingplan:Recurringmonthlyexpenses

Pleaserecordallofthebeneficiary’srecurringmonthlyexpenses,regardlessofwhetherthetrustwillbepayingforthemornot.

RECURRINGMONTHLYEXPENSES–NOEFFECTONBENEFITS

Utilities Transportation/Auto Phone $ Gas $ Cable/Internet $ Repairs $

Tolls $ HouseholdExpenses Licenseandregistration $ Repairs $ Insurance $ Supplies $ Publictransportation $ Furnishings $ Taxis,etc. $ Appliances $ Loanpayment $ Gardeningservices $ Other $ Housekeepingservices $

Clothing Personal/MedicalCare Clothes $ Medications $ Personalhygiene $ Entertainment Otherpersonal/medicalcare $ Movies,concerts,museums,etc. $

$ Insurance Travel Life $ Air,train,etc. $ Medical $

Other Other $

TOTAL: $__________________

RECURRINGMONTHLYEXPENSES–MAYAFFECTBENEFITSIFPAIDBYTRUST

Housing Utilities Rent $ Heating $ Mortgage $ Electricity $ Insurance $ Trash/Garbage $ Taxes $ Water $

Sewer $ Food Groceries $ Restaurants $

TOTAL:$__________________

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Spendingplan:Anticipatedone-timeexpenses

Pleaserecordanyone-timeexpensesthatyouanticipateinthenearfuture.Thislistdoesnotneedtobecomprehensive,butitwillhelpusthinkaboutthebeneficiary’scashneedsoverthenextcoupleofyears.Wehaveprovidedafewexamplesbelow.

ANTICIPATEDONE-TIMEEXPENSES

One-timeexpenses Amount AnticipateddateExample:Newcomputer $600 WithinthenextyearExample:Newwintercoat $150 November2016Example:Stationarybike $1000 Spring2017Example:Acupuncture $150 July2016Example:Electiveeyesurgery $2000 2018

TOTAL:$__________________

Click submit or save this file with a new file name and email to:

Shelley@gspt.org7