Self Funded Payback Trust

Self Funded Payback Trust
Once you have determined which type of Trust fits your situation and needs you should begin to work with an attorney to establish the appropriate trust. Remember that the first and most essential distinction to be made in deciding what kind of trust to create is where the money is coming from.

Step 1. Obtain an Attorney

Step 2. (Pooled) Download & Complete Forms (pdf)
	Self Funded Pooled Payback Trust Transfer Agreement (download Word file) Self Funded Payback Trust Life Care Plan (download Word file) Non-Legal Representation Disclosure Customer Privacy Policy Statement USA Patriot Act Customer Identification Form W-9 Request for Taxpayer Identification Number & Certification Online User Access Form Referral Follow Up Survey Required documentation with forms: Copy of Photo ID with Patriot Act form Certified Physician’s letter stating beneficiary’s disability or Supplemental Security Income (SSI)benefits letter or check stub from the Social Security Administration Power of Attorney for Property form (If POA agent is assigned) Physician’s Report (Cook County form CCP-211 or equivalent by county)

Step 3. Send Forms to:
	Life'sPlan, Inc. 2801 Finley Road Downers Grove, IL 60515

Notice Regarding USA Patriot Act Information
Important Information About Procedures for Opening a New Account with Life'sPlan, Inc.
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask for your name, address, date of birth (in the case of an individual) taxpayer identification number, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying document in order to verify the information that you have provided to us. We are required by law to attempt to match the information provided by you against lists issued by various governmental agencies to confirm that you are not a known or suspected terrorist or in any way affiliated with a known or suspected terrorist group.

If you have any questions about this process, please discuss them with our trust administrator. Thank you for your cooperation with this process.