Purchase of Primary Residence In order for CPT to consider the purchase of a house using trust assets, you must supply the information requested below. Value of Trust Account:Value of Trust Account: Price of house:Price of house: Amount requested:Amount requested: Percentage of Purchase Price:Percentage of Purchase Price: Is there any warranty on the property?:Is there any warranty on the property?: Has the house been inspected?:Has the house been inspected?: Address: Address: How will property be deeded?How will property be deed? Percentage of ownership by beneficiary:Percentage ownership by beneficiary: How will the shelter items listed below be paid & estimated monthly amount?How will the shelter items listed below be paid & estimated monthly amount? How will other expenses be paid & estimated monthly amount?How will other expenses be paid & estimated monthly amount? Do you plan on making renovations or making large purchases in relation to the property?Do you plan on making renovations or making large purchases in relation to the property? If yes, what and what is the estimated amount to be requested from the trust?If yes, what and estimated amount to be requested from trust? For beneficiaries receiving SSI, the purchase of a home and/or payments of a mortgage, real property taxes, rent, heating fuel, gas, electricity, water, sewer, & garbage removal may result in a reduction of benefits. The beneficiary’s ownership percentage must be equal to the percentage paid by the trust. Some exceptions do apply. Required Documentation: Appraisal or other documentation as to the value of the home Closing statement or similar document Please note, a final determination cannot be made until all support documentation has been received and reviewed. Beneficiary Checklist for the Purchase of a Home Please complete the form by initialing each blank to the left of the request and fill out each blank completely. If a blank is not applicable, write in “N/A”. Requests for purchase of home will not be considered until this form is completed.Name of Beneficiary - Blank Name of BeneficiaryName of Beneficiary Name of Beneficiary Advocate - Blank Name of Beneficiary AdvocateName of Beneficiary Advocate Name and relationship of person(s) requesting disbursement for home purchase - Blank Name and relationship of person(s) requesting disbursement for home purchasea. Name a. Relationship b. Name b. Relationship Acknowledge that Beneficiary has sufficient mental capacity to manage his or her own home - Blank Acknowledge that Beneficiary has sufficient mental capacity to manage his or her own homeAcknowledge that Beneficiary has sufficient mental capacity to manage his or her own homeYesNoIf Beneficiary does not have sufficient mental capacity to manage his or her own home, then acknowledge that his or her legal representative has legal authority to manage Beneficiary’s home. - Blank If Beneficiary does not have sufficient mental capacity to manage his or her own home, then acknowledge that his or her legal representative has legal authority to manage Beneficiary’s home. Provide copy of Power of Attorney with Real Property Authority Provide copy of Letters of Conservatorship of Estate Summary of Request for Home PurchaseProvide address of proposed home - Blank Provide address of proposed homeProvide address of proposed home Current amount of Beneficiary’s Sub-Account is $ - Blank Current amount of Beneficiary’s Sub-Account is $Current amount of Beneficiary’s Sub-Account is $ a. Requested distribution amount from Sub-Account for purchase of home by Beneficiary is $a. Requested distribution amount from Sub-Account for purchase of home by Beneficiary is $b. Percentage of Beneficiary’s Sub-Account requested isb. Percentage of Beneficiary’s Sub-Account requested is Acknowledge that no more than one-half of Beneficiary’s Sub-Account may be used for home purchase - Blank Acknowledge that no more than one-half of Beneficiary’s Sub-Account may be used for home purchase Acknowledge that in order to obtain disbursement for home request that home will be owned by Beneficiary as his or her primary residence - Blank Acknowledge that in order to obtain disbursement for home request, the home will be owned by Beneficiary as his or her primary residenceAcknowledge that it is solely within the trustee’s discretion to disburse trust funds (or refuse to disburse trust funds) so Beneficiary can purchase home in his or her own name even when no more than one-half of Beneficiary’s Sub-Account is used - Blank Acknowledge that it is solely within the trustee’s discretion to disburse trust funds (or refuse to disburse trust funds) so Beneficiary can purchase the home in his or her own name even when no more than one-half of Beneficiary’s Sub-Account is usedAcknowledge that in month of purchase of home, the beneficiary if an SSI recipient will trigger SSA income called In-Kind Support and Maintenance (ISM) that may reduce the SSI check Acknowledge that in the month of the purchase of the home, the beneficiary, if an SSI recipient, will trigger SSA income called In-Kind Support and Maintenance (ISM) that may reduce the SSI checkAcknowledge that the Beneficiary or his or her Representative Payee provides notice to the Social Security Administration and Department of Health Care Services as required - Blank Acknowledge that the Beneficiary or his or her Representative Payee must provide notice to the Social Security Administration and Department of Health Care Services as requiredProvide name and number of real estate broker who is assisting you and name of real estate broker assisting seller - Blank Provide the name and phone number of the real estate broker who is assisting you and the name and phone number of the real estate broker assisting the sellera. Name of your brokera. Name of your broker b. Phone number of your brokerb. Phone number of your brokerc. Name of seller’s brokerc. Name of seller’s broker d. Phone number of seller’s brokerd. Phone number of seller’s broker Acknowledge that Beneficiary or Beneficiary Advocate have personally inspected home for suitability for Beneficiary - Blank Acknowledge that the Beneficiary or Beneficiary Advocate has personally inspected home for suitability for BeneficiarySchedule a home appraisal or provide comparable sales near home - Blank Schedule a home appraisal or provide comparable sales near homeSend copy of home appraisal to CPT once completed or comparable home sale information - Blank Send a copy of the home appraisal to CPT once completed or comparable home sale informationProvide home inspection report to trustee - Blank Provide the home inspection report to TrusteeAcknowledge that if Beneficiary owns home in his or her own name the Department of Health Care Services has a right to recover against the Beneficiary’s “estate” for all Medi-Cal services provided to beneficiary after they die, the situation may not arise if the Beneficiary owns the home in a living trust, Beneficiary is encouraged to seek an attorney knowledgeable in this area to provide advice on the best way to manage home transfer after the death of the Beneficiary - Blank Acknowledge that if the Beneficiary owns the home in his or her own name, the Department of Health Care Services has a right to recover against the Beneficiary’s “estate” for all Medi-Cal services provided to beneficiary after they die. The situation may not arise if the Beneficiary owns the home in a living trust, so the Beneficiary is encouraged to seek an attorney knowledgeable in this area to provide advice on the best way to manage the home transfer after the death of the BeneficiaryHome Expenses and SustainabilityState estimated annual cost of property tax for home $ - Blank State estimated annual cost of property tax for home $State estimated annual cost of property tax for home $Obtain homeowners insurance for home - Blank Obtain homeowners insurance for homea. Provide annual cost of home insurance $a. Provide annual cost of home insurance $ b. Name of insurance brokerb. Name of insurance broker c. Name of home insurance companyc. Name of home insurance company List estimated cost to Beneficiary: - Blank List estimated cost to Beneficiary:a. Moving expenses $a. Moving expenses $b. Accessibility modifications or repairs to home $b. Accessibility modifications or repairs to home $c. Monthly utility costsi. Gas $i. Gas $ii. Electricity $ii. Electricity $iii. Water $iii. Water $iv. Sewer $iv. Sewer $v. Garbage $v. Garbage $vi. Cable $vi. Cable $vii. Internet $vii. Internet $d. Landscaping $d. Landscaping $e. Furnishingsi. Kitchen $i. Kitchen $ii. Living Room $ii. Living Room $iii. Dining Room $iii. Dining Room $iv. Master Bedroom $iv. Master Bedroom $v. Guest Bedroom(s) $v. Guest Bedroom(s) $vi. Other room $vi. Other room $Acknowledge that CPT and Beneficiary or Beneficiary Advocate must agree on which party is responsible for paying foregoing expenses and trustee is under no obligation to pay for any such items - Blank Acknowledge that CPT and the Beneficiary or Beneficiary Advocate must agree on which party is responsible for paying foregoing expenses and the Trustee is under no obligation to pay for any such itemsOthers Living in HomeList names and relationship of all persons expected to live in home: - Blank List names and relationship of all persons expected to live in home:a. Name a. Relationship b. Name b. Relationship c. Name c. Relationship d. Name d. Relationship e. Add additional sheet if necessarye. Add additional sheet if necessaryDescribe how much these people will pay on a monthly basis to assist with home expenses, describe: - Blank Describe how much these people will pay on a monthly basis to assist with home expenses:Describe how much these people will pay on a monthly basis to assist with home expenses, describe:Acknowledge that if other persons living in the home pay rent while home is owned by Beneficiary that if Beneficiary is an SSI recipient will cause a dollar-for-dollar reduction of his or her SSI check (after first $20) as unearned income. For example, if Beneficiary charges rent of $500 a month, it will reduce the SSI check by $480 a month. - Blank Acknowledge that if other persons living in the home pay rent while the home is owned by the Beneficiary, that if the Beneficiary is an SSI recipient, rent payments will cause a dollar-for-dollar reduction of his or her SSI check (after the first $20) as unearned income. For example, if the Beneficiary charges rent of $500 a month, it will reduce the SSI check by $480 a month.Acknowledge that if Beneficiary does not pay for his or her fair market share of utilities and Beneficiary is an SSI recipient will cause a reduction of the SSI check based off of In- Kind Support and Maintenance (ISM) income - Blank Acknowledge that if the Beneficiary does not pay for his or her fair market share of utilities and the Beneficiary is an SSI recipient it will cause a reduction of the SSI check based off of In- Kind Support and Maintenance (ISM) incomeI declare under penalty of perjury that the information provided in this form/packet is true and correct.Dated:Dated: MM slash DD slash YYYY Print Name:Print Name: Signature:Signature: Δ Download PDF
