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MS DOM HCBS Income Trust Document

EP&P/Appendix A-9-1

Revised July 2017

3) The Trustee will then be requested to make payment of this amount to the Division of Medicaid up to the total amount expended by the Division of Medicaid on behalf of the Settlor that has not previously been repaid to Medicaid. Failure to make the requested payments will result in the loss of Medicaid eligibility for the Settlor.

4) This trust will terminate upon the death of the Settlor; when the Settlor’s Medicaid eligibility is terminated; when the Settlor’s income no longer exceeds the current Medicaid income limits; or when the trust is otherwise terminated. At that time, any income amounts accumulated but undistributed shall be paid over to the Division of Medicaid, State of Mississippi, up to the total amount expended by the Division of Medicaid on behalf of the Settlor that has not previously been repaid to Medicaid.

(B) When requested, the Trustee shall furnish to the Division of Medicaid, State of Mississippi, an annual accounting to show all receipts and disbursements of the trust during the prior calendar year.

(C) The Trustee shall maintain the trust funds on deposit in a federally insured banking institution.

(E) No Trustee shall receive a Trustee’s fee for services rendered to the trust, however, reasonable bank charges will be allowed.

(F) The Trustee shall give written notice to the Division of Medicaid, State of Mississippi when the Settlor dies or when the trust is otherwise terminated.

(F) The provisions of this Trust shall be interpreted under the laws of the State of Mississippi. The effective date of this trust shall be _______________________________. IN WITNESS WHEREOF, this ____________________________ Income Trust Agreement has been executed on this the _____ day of __________, 20___.

___________________________________ Trustee

___________________________________ Settlor