Paul B. Bartlett, P.C.
A member of the National Academy of Elder Law Attorneys

335 N. Wilmot, Suite 410
Tucson, Arizona  85711
(520) 750-1061

Information needed to prepare the Miller Trust:
After you have answered the questions, click the submit button at the bottom of this page to transmit the information to the lawyer.

Who is requesting the Miller Trust ?        
Street Address
City, State Zip ,  
What is your title?
My relationship to the Patient is:
My phone number is:
My email address is:
The provisions of this Miller Trust are unique to Arizona

Patient is applying for Medicaid (ALTCS) in Arizona

  
Patient's Full Name
 Include Middle Initial or Middle Name if any		  
Patient's Gender
Select One		  
Patient Marital Status  
Only if the Patient is Married:
Income of Spouse.
If Patient is married, what is the gross amount of payments regularly received in the other spouse's name (not in the patient's name)? 
Trustee
First Name, Middle Initial, and Last Name
Trustee need not be an Arizona Resident		  
Alternate Trustee
First Name Middle Initial and Last Name
Alternate trustee need not be an Arizona Resident		  
Who will sign the trust on behalf of the patient?
Select either the patient himself or, if patient ALREADY has a durable financial power of attorney, the agent named in the power of attorney.		  
If the Patient is NOT signing the Miller Trust Himself:
Who is the Agent under the Power of Attorney who will sign the trust?
Provide First Name, Middle Initial if any and Last Name		  
Provide the Name of Each Income Source and the Amount it Pays Before any Deductions are taken out
Examples:
Source: Social Security       Gross Amount  $567
Source: Military Retirement Gross Amount $986
Please specify the name of any company issuing a pension check; e.g.
General Motors Pension
Source

  Gross Amount

 
Source

  Gross Amount

 
Source

  Gross Amount

 
Source

  Gross Amount

 
Where will the patient be receiving care?

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. 

 

Upon Clicking the SUBMIT BUTTON below, you will be returned to the previous page describing the steps to order a Miller Trust.  Once there, remember to proceed to Step 2 (payment) after you click the Submit Button below -- otherwise the lawyer will not be able to proceed with the preparation of your trust.