(Copy Receipt) SUPERIOR COURT OF WASHINGTON COUNTY OF ___________________ (Clerk's Date Stamp) In Re The Trust for: ___________________________________ An Incapacitated or Disabled Person CASE NO. ____________________ ORDER ESTABLISHING TRUST (CLERK'S ACTION REQUIRED) CLERK'S INFORMATION SUMMARY Due Date for Receipt(s) for Blocked Account: ____________________ Due Date for Bond: _____________________ Due Date for 1st Annual Account: ____________________ Due Date for Inventory: _____________________ Due Date for Statement of Need & Projected Disbursements: ______________________ Name, Address and Telephone for Trustee/Attorney: __________________________________ _____________________________________________________________________________ This matter came before the Court on a petition by a parent, guardian, grandparent, other ___________________________, to create and establish a trust characterized as a: Trust Resulting from the Settlement of a claim on behalf of a minor or incapacitated person in accord with SPR 98.16 w. ORDER ESTABLISHING TRUST - PAGE 1 OF 4 SPO TRU 02.0100 (02/2010) American LegalNet, Inc. www.FormsWorkFlow.com Special Needs Trust on behalf of a disabled person as authorized by 42 U.S.C. 1396p(d)(4)(A), WAC 388-513-1363 and WAC 388-561-0100. The beneficiary of the trust: is the subject of a guardianship. The guardian is _______________________. is not the subject of a guardianship. The trust document was drafted by ____________________________________. This person was selected by: the Court __________________________________________ A Guardian ad Litem for the beneficiary: was not appointed because: the trust was drafted by independent counsel per court Order the beneficiary is competent and eligible for a special needs trust due to physical disability only. was appointed and is _____________________________________________. The initial trustee(s) appear(s) to be free of any conflicts that might impair their independent judgment in the administration of the trust. The Court finds that the beneficiary is: a minor or incapacitated person and that creation of the trust would be in the best interest of the beneficiary. under the age of 65 years and is disabled within the criteria set forth at 42 USC 1382(c) and Social Security Act Section 1641(a)(3), and WAC 388-475-0050. He/she is qualified to be the beneficiary of such a trust, and further that the proposed Trust Agreement and the trust itself are in the best interests of the beneficiary. As such, the Trust is hereby created and established as set forth herein. The Court further finds that the trust is required for the protection of the beneficiary, and hereby directs the establishment and creation of the same as set forth herein, and within the terms of the trust itself. Now therefore it is ORDERED: ORDER ESTABLISHING TRUST - PAGE 2 OF 4 SPO TRU 02.0100 (02/2010) American LegalNet, Inc. www.FormsWorkFlow.com 1. The _________________________________ Trust, filed herewith is approved by the Court. This trust is hereby created, established and required by this Court. 2. The trustee(s) shall file annual accountings due no later than 90 days after the anniversary of the date of this order. Notice of each accounting shall be provided to ______________________________. 3. Bond is set in the amount of $_______________ and shall be approved by the Court prior to the funding of the trust, but in no event later than _______________________, 20 . The following accounts shall be blocked subject to the disbursement only by court order. ____________________________________________________________ A receipt for blocked account shall be filed by _____________________________, 20 4. The situs of the trust shall be deemed to be Spokane County, Washington. Unless approved by the Court, all proceedings concerning the administration of the trust shall be brought in the Spokane County Superior Court. 5. The appointment of a successor trustee shall be subject to Court approval. 6. The trust may be amended only by order of this Court. 7. The trustee must file an inventory of trust assets by ______________________, 20 In the event additional funding of the trust, the trustee shall file an amended inventory within 30 days thereafter. 8. The trustee shall file an outline of the beneficiaries projected needs and significant disbursements within 30 days of appointment and annually thereafter. 9. 10. Attorney fees incurred in the drafting of the trust in the amount of $__________ are found to be reasonable and are approved for payment to: _________________________. Other: ____________________________________________________ . . DATED AND SIGNED IN OPEN COURT THIS DAY OF _______________, 20 . ____________________________________________ Judge/Court Commissioner ORDER ESTABLISHING TRUST - PAGE 3 OF 4 SPO TRU 02.0100 (02/2010) American LegalNet, Inc. www.FormsWorkFlow.com Signature of Trustee/Attorney Printed Name of Trustee/Attorney, WSBA/CPG# Address Telephone/Fax Number City, State, Zip Code Email Address Signature of Guardian ad Litem Printed Name of Guardian ad Litem Address Telephone/Fax Number City, State, Zip Code Email Address ORDER ESTABLISHING TRUST - PAGE 4 OF 4 SPO TRU 02.0100 (02/2010) American LegalNet, Inc. www.FormsWorkFlow.com