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Miller Trust Information 

Please provide us with the information we request in the form below.  You can finish this form is about 5 minutes.  There are six steps:

• Who is requesting the Miller Trust?

• Who is the Patient?

• Who will be the trustee?

• Who will sign the trust?

• What income will be assigned to the trust?

• Pay the fee

Your privacy is assured.  We owe you a duty of attorney confidentiality, and we cannot share your information with anyone.  All information you give us, including your credit card information, is encoded using 128-bit encryption.  This means it cannot be captured or used, except in the preparation of your Miller Trust.

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	Who is Requesting the Miller Trust? The trust is commonly known as a Miller Trust, but can be called an Income Only Trust, and Income Cap Trust or an Income Assignment Trust
	Your Title* Mr. Ms. Mrs. Dr.
	Your First Name* Name of Person Requesting Miller Trust for Patient
	Your Middle Initial Name of Person Requesting Miller Trust for Patient
	Your Last Name* Name of Person Requesting Miller Trust for Patient
	Address* City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming State Zip Code
	My relationship to the patient is* Spouse Adult Child Friend Sibling Other relative Other
	Phone*
	Email*

»

	About the Patient
	Patient is applying for ALTCS Medicaid in Arizona* Yes No
	Patient's Full Name*
	Patient's Gender* Male Female
	Patient's Marital Status*   Single Married Divorced Widowed
	Monthly Income of Spouse* $ Gross amount before deductions

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	Trustee and Alternate
	Who will be trustee ?* Trustee cannot be the patient
	Who will be the alternate trustee?* Alternate trustee cannot be the patient

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	Signing the Income Only Trust
	Who will sign the trust on behalf of the Patient* Patient Agent Under Power of Attorney Select either the patient himself or, if patient ALREADY has a durable financial power of attorney, the agent named in the power of attorney.
	Who will sign the trust on behalf of the patient?* Who is the agent under the power of attorney?

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	INCOME
	Source*	Monthly Amount* $ Gross amount before deductions
	Source	Monthly Amount $ Gross amount before deductions
	Source	Monthly Amount $ Gross amount before deductions
	Source	Monthly Amount $ Gross amount before deductions

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	What income will be assigned to the trust?
	Where will the patient be receiving care?* Nursing Home Boarding Home Patient's own home or home of family or friends
	Where will the patient be receiving care?* Patient will be in a care facility - so assign all income to trust Agree - Care will be at home so assign the least income to trust Disagree - Care will be at home but assign all the income to trust anyway If the patient will be receiving care at home and receiving Home and Community Based Services (HCBS), we recommend that you allow us to word your trust such that only the smallest amount of the patient's income will be assigned to the Miller trust and still permit the patient to be income eligible. We do this to minimize the amount that the ALTCS program can recoup from the patient at death. Please indicate that you agree with this recommendation or disagree. Agreement means we will put less than all income sources in the trust. Disagreement means we will put all income sources in the trust.

» «    

	Pay for the preparation of the Income Only Trust and other documents The legal fee for the Income Only trust is $465. The fee includes detailed instructions about setting up the Miller Trust Bank Account and how to operate under a Miller Trust after it is set up.  It also includes model letters to pension sources asking them to transfer the pensions into the Income only trust bank account. Remember: the patient needs to be resource eligible for ALTCS, which means that he or she needs to spend down to $2,000 or below.  The legal fee for the Miller Trust is an appropriate spend down expense.
	Credit Card
	Name on the Credit Card*
	Expiration Date* Month   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year   2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
	Security Code On Mastercard, Visa and Discover this is a 3 digit number on the right side of the signature strip on the back of the card. On an American Express Card this is a four digit number on the face of the card.

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A member of the State Bar of Arizona since 1976 serving Tucson and Southern Arizona

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