1) The customer has all of their income assigned to the Income-Only Trust and lives in a Home and Community Based Services (HCBS) living arrangement

The customer is applying for ALTCS in March 2020. He has an income-only trust.

The customer:

Lives in an assisted living home;

Gets $1,000.00 per month in Social Security income and $2,000.00 per month from a pension. Both incomes are assigned to the income-only trust; and

Pays $144.60 for Medicare Part B and $200.00 per month for other health insurance.

If he is approved for ALTCS, his SOC before the Medicare Buy-in occurs will be $306.40 . His SOC after the Medicare buy-in will be $451.00.

The DE-313 should be completed as follows:

Month: Amounts Provided by Benefits and Eligibility Specialist 03/2020 04/2020 05/2020 06/2020 07/2020 08/2020 Income Assigned to the Trust: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 The ALTCS Share of Cost (SOC): 306.40 306.40 306.40 306.40 451.00 451.00 451.00 Personal Needs Allowance:* 2349.00 2349.00 2349.00 2349.00 2349.00 2349.00 2349.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: 344.60 344.60 344.60 344.60 200.00 200.00 200.00 Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00

Month: Amounts Provided by Benefits and Eligibility Specialist 09/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 The ALTCS Share of Cost (SOC): 451.00 451.00 451.00 451.00 451.00 451.00 451.00 Personal Needs Allowance:* 2349.00 2349.00 2349.00 2349.00 2349.00 2349.00 2349.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: 200.00 200.00 200.00 200.00 200.00 200.00 200.00 Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00