1) The trust does not receive income

The customer is applying for ALTCS in June 2020. She has a special treatment trust which requires a completed Special Treatment Trust Anticipated Disbursements Form (DE-312). She has $1,500.00 in countable income that is not assigned to the trust. She lives at home and does not have a share of cost.

The only thing titled to the trust is a financial account with $500,000.00 from a legal settlement.

The customer is requesting the following disbursements:

$100.00 per month in legal fees for the attorney handling the trust

$200.00 per month for personal care services from an AHCCCS-registered provider

$500.00 per month for rent

A one-time disbursement of $750.00 for the purchase of a prepaid burial plan funded by an irrevocable life insurance policy, to be purchased in August 2020

All the requested disbursements are considered allowable disbursements. Since the $500.00 is for shelter, it is counted in the income determination. Her total countable income, including income outside the trust, would be $2,000.00. The other requested disbursements are not counted as income.

The DE-312 should be completed as follows:

Month: Amounts Provided by Benefits and Eligibility Specialist 06/2020 07/2020 08/2020 09/2020 10/2020 11/2020 Income Assigned to the Trust: The ALTCS Share of Cost (SOC): Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees 100.00 100.00 100.00 100.00 100.00 100.00 Medical Insurance: Medical Expenses: 200.00 200.00 200.00 200.00 200.00 200.00 Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* 500.00 500.00 500.00 500.00 500.00 500.00 Pre-Paid Burial Expenses:(See back page) 750.00 Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 800.00 800.00 1550.00 800.00 800.00 800.00

Month: Amounts Provided by Benefits and Eligibility Specialist 12/2020 01/2021 02/2021 03/2021 04/2021 05/2021 Income Assigned to the Trust: The ALTCS Share of Cost (SOC): Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees 100.00 100.00 100.00 100.00 100.00 100.00 Medical Insurance: Medical Expenses: 200.00 200.00 200.00 200.00 200.00 200.00 Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* 500.00 500.00 500.00 500.00 500.00 500.00 Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 800.00 800.00 800.00 800.00 800.00 800.00