Disability Determination for Trust Eligibility. The Beneficiary is receiving SSI or SSDI (Indicate which type): If no finding of disability from Social Security Administration, provide details as applicable: Denial – Appeal Status (Notes): Over resource limits to apply for Social Security Supplemental Security Income (will apply upon asset transfer to Trust) (Notes): New York State forms DSS 1151 or LDSS 486T completed, submitted and pending approval (Notes): ACT for Life Services: Advocacy, Comprehensive Planning, and Trust Services for Individuals with Disabilities Page 5 Third parTy-funded TrusT for people wiTh disabiliTies, as amended and resTaTed on may 26, 2005 sponsor agreemenT addendum Basic description of disability / diagnosis: Proof of disability required, indicating your claim number (such as benefits award letter, Form SSA-1099, annual rate letters, other correspondence indicating type of Social Security Income). The Third Party-Funded Trust for People with Disabilities, as Amended and Restated on May 26, 2005 is a Trust developed for use by individuals with disabilities according to federal and state law. Life Services, by agreeing to accept assets and funds into the Trust, per the Sponsor Agreement, agrees only to manage the trust funds in accordance to the terms of the Master Trust Agreement and in compliance with applicable federal and state law and regulation. It is the sole responsibility of the SPONSOR / ESTABLISHER / BENEFICIARY / DONOR to determine whether donor is “disabled” as that term is defined under federal law and to determine if they have the legal authority to transfer assets and funds to fund the Trust, and what impact that a transfer of property to the Trust will have on the beneficiary’s eligibility to obtain or maintaining government entitlement benefits.
