Georgia Miller Trust / Qualified Income Trust (QIT)

GEORGIA QUALIFIED INCOME TRUST (MILLER TRUST)

(Irrevocable Income-Only Trust — 42 U.S.C. § 1396p(d)(4)(B) — Ga. Comp. R. & Regs. 111-3-8)

ARTICLE I — DECLARATION OF TRUST

1.1 Trust Creation. I, [FULL LEGAL NAME OF SETTLOR], of [CITY], [COUNTY] County, Georgia (the "Settlor," "Grantor," and "Beneficiary"), hereby establish this Qualified Income Trust (the "Trust") on [__/__/____] under and pursuant to:

(a) 42 U.S.C. § 1396p(d)(4)(B) (federal safe harbor for Qualified Income Trusts);
(b) Ga. Comp. R. & Regs. 111-3-8 (DCH Estate Recovery rules) and the DCH Medical Assistance Eligibility policy manual;
(c) O.C.G.A. § 49-4-141 et seq. (Georgia Medical Assistance Act);
(d) The Georgia Trust Code, O.C.G.A. ch. 53-12.

1.2 Name of Trust. This Trust shall be known as the "[FULL LEGAL NAME OF SETTLOR] Qualified Income Trust dated [__/__/____]."

1.3 Purpose. The sole and exclusive purpose of this Trust is to enable the Settlor to establish and maintain Medicaid eligibility for long-term care services in Georgia — including nursing facility care, Community Care Services Program (CCSP), Service Options Using Resources in a Community Environment (SOURCE), and the Independent Care Waiver Program (ICWP) — by diverting the Settlor's monthly income that exceeds the Georgia Medicaid income cap (300% of the SSI Federal Benefit Rate) into this Trust in accordance with 42 U.S.C. § 1396p(d)(4)(B).

1.4 Trust is Irrevocable. This Trust is IRREVOCABLE. The Settlor expressly waives and disclaims any power to revoke, amend, modify, alter, or terminate this Trust except as required to maintain compliance with federal or Georgia Medicaid law or as ordered by a court of competent jurisdiction.

1.5 No Resources; Income Only. Only income of the Settlor (including, without limitation, Social Security retirement and disability benefits, pension payments, annuity payments, Veterans Administration benefits, railroad retirement benefits, and any other recurring income) shall be deposited into this Trust. No countable resources, assets, or principal of the Settlor shall be transferred into or held by this Trust.

1.6 Trust Established in Georgia. The Settlor and Trustee acknowledge that this Trust is established, funded, and administered in the State of Georgia. A Qualified Income Trust established in another state may not be used to qualify the Settlor for Georgia Medicaid.

1.7 No Backdating. This Trust is effective only from and after the date of execution. The Settlor and Trustee certify that this instrument has not been backdated and shall not be used to claim eligibility for any period preceding the date of execution and funding.

ARTICLE II — PARTIES

2.1 Settlor / Beneficiary.

• Name: [FULL LEGAL NAME OF SETTLOR]
• Date of Birth: [__/__/____]
• Social Security Number (last 4): xxx-xx-[____]
• Georgia Medicaid ID (if assigned): [____________________]
• Address: [STREET], [CITY], GA [ZIP]

2.2 Trustee. The initial Trustee shall be:

• Name: [FULL LEGAL NAME OF TRUSTEE]
• Relationship to Settlor: [__________] (e.g., adult child, sibling, professional fiduciary, Georgia bank or trust company)
• Address: [STREET], [CITY], [STATE] [ZIP]
• Telephone: [(___) ___-____]

2.3 Successor Trustee. If the initial Trustee resigns, dies, becomes incapacitated, or is otherwise unable or unwilling to serve, the successor Trustee shall be [FULL LEGAL NAME OF SUCCESSOR TRUSTEE], of [ADDRESS]. If no named successor is able and willing to serve, a successor shall be appointed by a Georgia court of competent jurisdiction upon petition of any interested person.

2.4 Primary Remainder Beneficiary — Georgia Department of Community Health. As required by 42 U.S.C. § 1396p(d)(4)(B)(iii), O.C.G.A. § 49-4-147.1, and Ga. Comp. R. & Regs. 111-3-8, the Georgia Department of Community Health, Division of Medical Assistance ("DCH") is hereby designated the primary remainder beneficiary of this Trust, up to the total amount of medical assistance paid on behalf of the Settlor under the Georgia Medicaid program.

Notice to DCH shall be sent to:
Georgia Department of Community Health
Division of Medical Assistance — Estate Recovery Program
2 Peachtree Street NW
Atlanta, GA 30303

2.5 Contingent Remainder Beneficiaries. After full satisfaction of DCH's claim under Section 2.4, any remaining trust property shall be distributed as follows:

☐ To the Settlor's estate
☐ To: [FULL LEGAL NAME(S) OF CONTINGENT BENEFICIARY/IES] in the following shares: [____________________]
☐ Per stirpes to the Settlor's descendants

ARTICLE III — FUNDING OF THE TRUST

3.1 Income Subject to Trust. The following items of the Settlor's gross monthly income shall be deposited into the Trust bank account each month (check all that apply at funding):

3.2 Funding Method. The Trustee shall open a dedicated checking account in the name of "[FULL LEGAL NAME OF SETTLOR] Qualified Income Trust, [TRUSTEE NAME], Trustee" at a federally-insured Georgia financial institution. All deposits required under Section 3.1 shall be made into this account each calendar month. No co-mingling with personal funds of the Settlor or the Trustee is permitted.

3.3 Monthly Funding Required. Funding of the Trust must occur every calendar month in which the Settlor is enrolled in or applying for Georgia Medicaid long-term care. Failure to fund the Trust in a given month may result in loss of Medicaid eligibility for that month and recoupment of benefits.

3.4 No Resources. The Trustee shall not accept any transfer of resources (real estate, vehicles, bank accounts not constituting current-month income, securities, life-insurance cash value, or other countable assets) into the Trust. Any such transfer received in error shall be returned to the source within thirty (30) days.

3.5 Account Emptied Each Month. Consistent with Georgia DCH policy, all funds deposited in the QIT account in a given calendar month shall be fully disbursed in accordance with Article IV within that same calendar month, except for a de minimis administrative reserve for bank fees not to exceed $[__________].

ARTICLE IV — DISTRIBUTIONS DURING THE SETTLOR'S LIFETIME

4.1 Mandatory Disbursement Priority. The Trustee shall disburse the funds in the Trust each calendar month in the following order, consistent with Georgia DCH / DFCS long-term care Medicaid policy:

First — Personal Needs Allowance (PNA). To or for the benefit of the Settlor, the current Georgia Medicaid Personal Needs Allowance for an institutionalized individual (currently $[____] per month; confirm current amount with DFCS).

Second — Community Spouse Monthly Income Allowance. If applicable, the monthly maintenance needs allowance for the community spouse, [NAME OF COMMUNITY SPOUSE], as calculated and approved by DFCS under 42 U.S.C. § 1396r-5.

Third — Dependent Family Allowance. If applicable, the monthly maintenance allowance for any dependent family member as authorized by DFCS.

Fourth — Health Insurance Premiums and Approved Medical Expenses. Medicare Part B and Part D premiums, Medigap or supplemental insurance premiums, and other non-covered medical expenses approved by DCH/DFCS.

Fifth — Patient Liability / Cost of Care. To the nursing facility, CCSP/SOURCE/ICWP provider, or other long-term care provider serving the Settlor, in the amount of the Settlor's patient liability as determined by DFCS.

4.2 No Discretionary Distributions. The Trustee has no discretion to make distributions other than as enumerated in Section 4.1. Distributions to the Settlor in excess of the PNA, or to any third party other than as authorized in Section 4.1, are prohibited and may constitute disqualifying transfers under O.C.G.A. § 49-4-141 et seq. and federal Medicaid transfer-of-asset rules.

4.3 Records of Monthly Disbursement. The Trustee shall retain bank statements, canceled checks, electronic payment confirmations, and receipts evidencing each monthly deposit and disbursement, and shall produce such records on request to DCH or DFCS.

ARTICLE V — TERMINATION AND DISTRIBUTION ON DEATH OF SETTLOR

5.1 Termination Event. This Trust shall terminate upon the death of the Settlor.

5.2 Notice to DCH. Within thirty (30) days of the Settlor's death, the Trustee shall provide written notice to the Georgia Department of Community Health, Estate Recovery Program, at the address in Section 2.4, together with a copy of the Settlor's death certificate.

5.3 Payment to DCH — Primary Remainder. Upon termination, the Trustee shall pay all funds then remaining in the Trust to DCH, up to an amount equal to the total medical assistance paid on behalf of the Settlor under the Georgia Medicaid program, pursuant to 42 U.S.C. § 1396p(d)(4)(B)(iii), O.C.G.A. § 49-4-147.1, and Ga. Comp. R. & Regs. 111-3-8.

5.4 Hardship Waiver Acknowledgment. Consistent with Ga. Comp. R. & Regs. 111-3-8-.08, hardship waivers from estate recovery are available only on written request and only for the period during which the undue hardship exists; an estate of $25,000 or less in gross value is exempt from estate recovery, but this exemption does not by its terms apply to trust property held under this Trust.

5.5 Distribution of Excess. After DCH has been paid in full, any remaining Trust property shall be distributed under Section 2.5.

5.6 Final Accounting. The Trustee shall provide DCH, and any contingent beneficiary, a final accounting of all Trust receipts and disbursements within ninety (90) days of the Settlor's death.

ARTICLE VI — TRUSTEE POWERS, DUTIES, AND ADMINISTRATION

6.1 General Powers. Subject to the limitations of this Trust and applicable federal and Georgia Medicaid law, the Trustee shall have all powers conferred by O.C.G.A. ch. 53-12 (Georgia Trust Code) necessary to administer this Trust, including the power to open and maintain a fiduciary bank account, to deposit income, to make the disbursements authorized in Article IV, to maintain books and records, to file tax returns, and to communicate with DCH and DFCS.

6.2 Standard of Care. The Trustee shall administer this Trust in good faith and with the care of a prudent fiduciary, consistent with O.C.G.A. § 53-12-261 (Trustee's duties).

6.3 Records and Reporting. The Trustee shall maintain complete records of all deposits to and disbursements from the Trust account and shall provide such records on request to DCH, DFCS, the Settlor, the Settlor's authorized representative, any guardian, conservator, or agent under a durable power of attorney, and any contingent beneficiary.

6.4 Trustee Compensation. The Trustee shall serve ☐ without compensation / ☐ for reasonable compensation in the amount of $[__________] per month, subject to DCH/DFCS approval as a deductible administrative expense.

6.5 Bond. The Trustee shall serve ☐ without bond / ☐ with bond in the amount of $[__________].

6.6 No Modification of Medicaid-Required Terms. No provision of this Trust may be construed or applied in a manner inconsistent with 42 U.S.C. § 1396p(d)(4)(B), Ga. Comp. R. & Regs. 111-3-8, or applicable DCH/DFCS policy. To the extent any provision is so inconsistent, it shall be deemed reformed to comply.

ARTICLE VII — MEDICAID PROGRAM ACKNOWLEDGMENTS

7.1 Program Acknowledgment. The Settlor acknowledges that this Trust is being established in connection with an application for Georgia Medicaid long-term care benefits, which may include nursing facility care under the State Plan, the Community Care Services Program (CCSP), the SOURCE program, the Independent Care Waiver Program (ICWP), or other approved long-term services and supports.

7.2 Eligibility Determination by DFCS. Eligibility for Georgia Medicaid is determined by the Georgia Division of Family and Children Services ("DFCS") under the Department of Human Services, applying the policies of DCH.

7.3 Estate Recovery Acknowledgment. The Settlor acknowledges that, upon the Settlor's death, DCH has the right and obligation under 42 U.S.C. § 1396p(b), O.C.G.A. § 49-4-147.1, and Ga. Comp. R. & Regs. 111-3-8 to recover from the Settlor's estate (including this Trust as the primary remainder beneficiary) the amount of Medicaid benefits paid on the Settlor's behalf.

7.4 No Asset Protection. The Settlor acknowledges that this Trust is not an asset protection vehicle, does not shield property from Medicaid eligibility determinations, and does not avoid estate recovery as to the funds held herein.

ARTICLE VIII — MISCELLANEOUS

8.1 Governing Law. This Trust shall be governed by the laws of the State of Georgia and applicable federal Medicaid law.

8.2 Situs. The situs of this Trust is [COUNTY] County, Georgia.

8.3 Severability. If any provision of this Trust is held invalid, the remaining provisions shall remain in full force and effect.

8.4 Spendthrift Provision. To the maximum extent permitted by 42 U.S.C. § 1396p(d)(4)(B) and O.C.G.A. § 53-12-80 et seq., the interest of the Settlor in this Trust is subject to a spendthrift restriction; provided, however, that nothing in this Section shall limit DCH's rights as primary remainder beneficiary or its right of estate recovery.

8.5 Counterparts. This Trust may be executed in counterparts, each of which shall constitute an original.

ARTICLE IX — EXECUTION

IN WITNESS WHEREOF, the Settlor and the Trustee have executed this Qualified Income Trust on the date first written above.

SETTLOR:

Signature: [____________________________________]
Printed Name: [FULL LEGAL NAME OF SETTLOR]
Date: [__/__/____]

TRUSTEE ACCEPTANCE:

The undersigned hereby accepts the office of Trustee of this Qualified Income Trust and agrees to administer it in accordance with its terms and applicable law.

Signature: [____________________________________]
Printed Name: [FULL LEGAL NAME OF TRUSTEE]
Date: [__/__/____]

WITNESSES

The foregoing instrument was signed in our presence by the Settlor (or by a person authorized to sign on the Settlor's behalf), who declared it to be the Settlor's Qualified Income Trust, and we, at the Settlor's request and in the Settlor's presence and in the presence of each other, hereunto subscribe our names as witnesses on [__/__/____].

NOTARY ACKNOWLEDGMENT

STATE OF GEORGIA
COUNTY OF [____________]

Personally appeared before me, the undersigned officer authorized to administer oaths in the State of Georgia, [FULL LEGAL NAME OF SETTLOR], who is ☐ personally known to me or ☐ produced [____________________] as identification, and [FULL LEGAL NAME OF TRUSTEE], who is ☐ personally known to me or ☐ produced [____________________] as identification, who, after being duly sworn, acknowledged the execution of the foregoing Qualified Income Trust as their free and voluntary act and deed for the purposes set forth therein, this [__] day of [__________], 20[__].

Notary Public Signature: [____________________________]
Printed Name: [____________________________]
Notary Commission County: [____________________]
My Commission Expires: [__/__/____]
(Notary Seal)

SCHEDULE A — INITIAL FUNDING SCHEDULE

Total Monthly Funding Estimate: $[__________]

Georgia Medicaid Income Cap (300% SSI FBR) at Funding: $[__________]
Personal Needs Allowance at Funding: $[__________]

SOURCES AND REFERENCES

• 42 U.S.C. § 1396p(d)(4)(B) — Qualified Income Trust safe harbor
• 42 U.S.C. § 1396p(b) — Medicaid estate recovery
• 42 U.S.C. § 1396r-5 — Spousal impoverishment
• Ga. Comp. R. & Regs. 111-3-8 — DCH Estate Recovery (definitions, notice, hardship waiver)
• Ga. Comp. R. & Regs. 111-3-8-.08 — Hardship Waiver
• O.C.G.A. § 49-4-141 et seq. — Georgia Medical Assistance Act
• O.C.G.A. § 49-4-147.1 — Estate recovery authority
• O.C.G.A. ch. 53-12 — Georgia Trust Code
• Georgia Department of Community Health (DCH), Division of Medical Assistance
• Georgia Division of Family and Children Services (DFCS) eligibility policy manual
• CCSP, SOURCE, and ICWP long-term care programs