Page 108

- 2500 Irrevocable burial arrangement 6/11 $ 0 Remaining in savings account + 0 Countable value of $1,500 face value 0 Resources Resource total is reduced on 6/11, and if MN, this case is eligible 6/11. If CN, case is not eligible until 7/1. XIV. A/B IS A BENEFICIARY OF A TRUST Use the following information as a Guide to Trust. TYPE OF REVOCABLE IRREVOCABLE SPECIAL TRUST NEEDS OR POOLED ASSET CREATED CREATED CREATED WITH CREATED WITH CREATED CREATED SOURCE WITH WITH ASSETS OF NON­ ASSETS OF A/B WITH ASSETS WITH ASSETS OF ASSETS OF A/B OF A/B ASSETS OF NON-A/B* A/B A/B OR NON-AR DATE CREATED ANY DATE ANY DATE ANY DATE PRIOR TO 4-1-94 4-1-94 OR LATER 4-1-94 OR LATER RESERVE NO RESERVE VALUE CURRENT PRINCIPAL AMOUNT OF PRINCIPAL THAT CAN BE DISBURSED BASED ON THE TERMS OF THE TRUST. IF THE TERMS ALLOW TRUSTEE DISCRETION, COUNT THE AMOUNT HE AGREES TO MAKE AVAILABLE. AMOUNT OF PRINCIPAL THAT CAN BE DISBURSED BASED ON THE TERMS OF THE TRUST (THIS MEANS ALLOW EXCULPATORY CLAUSES). IF THERE ARE NO RESTRICTIONS, COUNT TOTAL PRINCIPAL TOTAL AMOUNT THAT CAN BE DISBURSED UNDER ANY CIRCUMST ANCES. (DISREGARD EXCULPAT ORY CLAUSES AND ANY RESTRICTI ONS ON TIME OR USE OF NO RESERVE VALUE THAT CAN BE DISBURSED. DISBURSE MENTS) TRANSFER NO TRANSFER TOTAL AMOUNT DISBURSED TO ANYONE OTHER THAN THE A/B NO TRANSFER AMOUNT THAT IS UNAVAILABLE TO THE A/B BASED ON THE TERMS PLUS AMOUNT DISBURSED TO ANYONE OTHER THAN THE A/B ANY PORTION OF THE TRUST THAT IS NOT COUNTED IN RESERVE IS CONSIDERED A TRANSFER NO TRANSFER 108