Section 1: Contact Information

Full name

Phone number

Email address

Relationship to beneficiary

Beneficiary full legal name

Beneficiary date of birth

Beneficiary current address

Section 2: Disability & Benefits Status

Social Security disability determination?

Yes

No

Pending

Currently receiving Medicaid?

Yes

No

Unsure

Section 3: Purpose of the Trust

Describe the situation

Section 4: Funding Source (Critical)

Estimated funding amount

Have funds already been received?

Yes

No

Funds pending

Section 5: Trustee Information

Proposed trustee full name

Trustee address

Trustee phone

Will there be a successor trustee?

Yes

No

Section 6: Distribution Intent

Special instructions for use of funds

Section 7: Remainder Beneficiaries

Who should receive remaining funds after beneficiary passes?

Acknowledgment re Medicaid payback if funded with beneficiary's money and Medicaid is received

Yes

No

I need clarification

Section 8: Urgency & Court Involvement

Is court approval required?

Yes

No

Unsure

Is there a deadline?

Yes

No

Section 9: Acknowledgment & Disclaimer

I understand Legalize Docs Plus is a document preparation service and does not provide legal advice. I acknowledge that this document should be reviewed by a licensed Michigan attorney prior to funding.

I confirm the information provided is accurate to the best of my knowledge.

Upload supporting documents (optional)

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