public benefits presented by: joshua l. brothers dussault law group (206) 324-4300 e-mail:...
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Public Benefits
Presented by:Joshua L. Brothers
Dussault Law Group(206) 324-4300
e-mail: [email protected]
www.dussaultlaw.com
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Public Benefits Overview
• Federal– Social Security
• SSI - $674/mo max• SSDI - varies
– Medicare• Hospital• Doctor Visits• Prescription Drugs• Limited Rehab
• State– Medicaid
• DSHS• Medical Assistance• Long Term Care
– DDD• Extended dental• Family Support• Waivers• Residential• Work & Education
– DVR– Food Stamps– Welfare
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Eligibility for Social Security and Medicaid/Medicare
• SSI/Medicaid– Disabled, blind, >65
• SGA - $1,000/month– “Means tested”
• Income ($20 exemption)– Earned - $2:$1 ($65
exemption)– Unearned - $1:$1– ISM – 1/3rd reduction
• Resources (< $2000)• Exempt Assets –
– Residence (<$500k) – Vehicle (any value)– Personal effects– SNT– Burial, funeral, term
insurance
• “SSA”/Medicare– Disabled, blind, >65
• SGA - $1,000/month– “Entitlement
program”• Individuals who have
paid FICA taxes in the last 20 of 40 quarters prior to disability
– Survivor, Retirement, and Disability
– Medicare available when: over 65 or meets SSA disability definition, 29 months post injury
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Supplemental Security Income
(SSI)• Provides Cash benefit of up to $674 to be
utilized for food and shelter expenses (as of 1/09).
• Some States provide cash supplements to base SSI limit
• “Gatekeeper” to Medicaid and other public benefit programs
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SSI Income
• Earned Income:– Sources: wages, self employment, royalties and any
other income received from employment activities– $20 general exclusion– $65 earned income exclusion– $2:$1 reduction in SSI benefits
• Unearned Income– Sources: Payments from annuities or trusts,
alimony/support payments, dividends, interest, gifts, other SSA benefits, etc.
– $20 general exclusion– $1:$1 reduction in SSI benefits
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SSI Income (ISM)
• In-Kind Support & Maintenance• Any item an individual receives in cash or
in-kind that can be used to meet his or her need for food or shelter.
• Reduction to SSI benefits lesser of:– 1/3rd reduction (presumed maximum value –
PMV)– $1:$1 reduction
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SSI Calculation Example
• Individual earns $275 in wages in a month• Receive $300 Gift from family
Maximum SSI Amount $674
Earned Wages $275
Less $65 exclusion $210
½ of remaining earned income ($2 for $1)
$105
Unearned Income($1 for $1) $300
Less $20 exclusion $280
Total Countable Income $385
Total SSI Benefit $289
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SSI Asset Limitations• Individual limit – $2,000• Family limit – $3,000• Calculated as 1st of the month• Exempt Resources:
– Residence of $500,000 or less– Vehicle with no limitation– Personal effects– SNT– Burial, funeral, term insurance
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SSI “Gate Keeper” to Medicaid
• SSI of $1 = categorical eligibility for Medicaid
• Other Medicaid medical programs exist• Medicaid Waiver programs typically have
different eligibility criteria which may or may not be income/asset sensitive.
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SSI/Medicaid Parental Deeming
• Parental income and assets count against minor child’s eligibility.
• Income eligibility based upon sliding scale based upon gross income less various exemptions.
• Income amount vary from base level which will allow full SSI amount to maximum level which will completely disqualify
• Asset Limitation: $3,000 per family with some exemptions.
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Parental Deeming-EligibilityGeneral Guidelines Only (2006)
Gross Monthly Income:
All Earned Income:
All Unearned Income:
# of ineligible Children in House
One ParentHousehold
Two Parent Household
One Parent Household
Two Parent Household
0 $2,537 $3,139 $1,246 $1,547
1 $2,838 $3,440 $1,547 $1,848
2 $3,139 $3,741 $1,848 $2,149
3 $3,440 $4,042 $2,149 $2,450
4 $3,741 $4,343 $2,450 $2,751
5 $4,042 $4,644 $2,751 $3,052
6 $4,343 $4,945 $3,052 $3,353
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Social Security Disability
Income (SSDI)• “Earned” Benefit• Based upon work history (20/40 rule)• Variable cash benefit• Dual eligibility for SSI/SSDI possible• Who’s work history?
– Own– Spouse– Parent (DAC)– Grandparent
• DAC benefit:– ½ during parent’s lifetime– ¾ after parent’s death
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Social Security Appeals
• Notice of denial, termination, reduction or overpayment• Request for Reconsideration• Hearing before an Administrative Law Judge
– Fact finding role of hearing officer– Presentation of evidence
• Social Security Council• Federal District Court• Federal Court of Appeals (Circuit Court)• Federal Supreme Court
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Medicaid Administration in
WADep’t of Social & Health Services
(DSHS)
Division of Developmental
Disabilities (DDD)
Aging and Adult Services (AAS)
Division ofVocational
Rehabilitation (DVR)
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Medicaid
• Coverage: – Medical Assistance (general medical care,
hospitalization, physicians, medications, medical testing, surgical procedures, durable medical equipment, medical supplies, therapy, etc.)
– Long Term Care (LTC)
• “Medically necessary”• Limitations: Vision, dental, “experimental” or non-
traditional treatments/therapies
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Categorically vs. Medically Needy• Categorically Needy
– Medical Assistance– Long Term Care– SSI eligibility
• Medically Needy– Medical Assistance
• Not on SSI due to too much income• Spend down implemented
– Based on income over maximum SSI benefit of $674/month.– 3 or 6 months– Ex. Income of $774/month results in spend down of $300 for 3 months or $600 for 6 months
• Exception for recipient of SSDI based on parent’s work history (WAC 388-475-0880)
– Long Term Care has different income requirement & participation used, not spend downs.
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Long Term Care Services“The department provides long-term care services through programs that are designed to help you remain in the community. These programs
offer an alternative to nursing home care.”
WAC 388-106-0015
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Long Term Care Services• Programs
– Medicaid Personal Care (MPC)– Community Options Program Entry System (COPES)– Medically Needy In-Home or Residential Waivers– Respite Care– DDD Programs
• Settings– Own home– Assisted living– Adult family home– Companion homes– Host homes
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LTC Eligibility in Washington
• SSI = Categorically Eligible• Non-SSI Eligibility
– Income• Individual: $2,022.00• Couple: $4,044.00• May be required to participate in cost of care (amount will vary)
– Resource• Individual: $2,000.00• Community Spouse Resource Allowance: $48,639.00
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Comprehensive Assessment Reporting
Evaluation (CARE) Tool• Develops Individual Support Plan (“ISP”) and
determines personal care hours• Algorithm determines personal care hours
– Structured for elderly, not developmentally disabled• Changes to mood and behavior• DDD Assessment
– 0-416 hours
• Additional Hours under an Exception to Rule possible• WAC 388-106-0050 to -0145
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Basic Structure of CARE
Tool• Placement in Classification Group (A to E) to
determine “base hours”– Exceptional Care (ADL scores & additional requirements)– Clinically Complex (defined conditions & ADL scores)– Cognitive Performance (scores of 0-6)– Mood & Behaviors (defined conditions with frequency OR
behavior point score of 0-12)– Activities of Daily Living or “ADL” (scores of 0-28)
• Informal supports reduce the number of base hours
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Determining In-Home Hours
Classification
ADL or Behavior Point
Score Classification Group Base HoursGroup E
EC = YesAND
M&B = Yes or No AND
CPS = 0-6
ADL (26-28) E High 416
ADL (22-25) E Med 346
Group DCPS = 4-6
ANDCC = Yes
AND M&B = Yes or No
OR
CPS = 5-6AND
CC = NoAND
M&B = Yes or No
ADL (25-28) D High 277
ADL (18-24) D Med-High 234
ADL (13-17) D Med 185
ADL (2-12) D Low 138
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Determining In-Home Hours
Classification
ADL or Behavior Point
Score Classification Group Base HoursGroup CCPS = 0-3
ANDCC = Yes
ANDM&B = Yes or No
ADL (25-28) C High 194
ADL (18-24) C Med-High 174
ADL (9-17) C Med 132
ADL (2-8) C Low 87
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Determining In-Home Hours
Classification
ADL or Behavior Point
Score Classification Group Base HoursGroup B
M&B = YesAND
CC = NoAND
CPS = 0-4
OR
CPS = 2-6AND
BPS > 1AND
ADL > 1
OR
CPS >2AND
ADL >1
ADL (15-28) B High 147
ADL (5-14) B Med 82
ADL (0-4) B Low 47
BPS (>12) B High 147
BPS (7-11) B Med-High 101
BPS (5-6) B Med 82
BPS (1-4) B Low 47
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Determining In-Home HoursClassification
ADL or Behavior Point
ScoreClassification
Group Base HoursGroup AM&B = No
ANDCC =No
ANDCPS = 0-4
ADL (10-28) A High 71ADL (5-9) A Med 56ADL (0-4) A Low 26
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Activities of Daily Living
• Scores from 0 to 28• ADLS
– Personal Hygiene– Bed Mobility– Transfers– Eating– Toilet Use– Dressing– Either:
• Locomotion in Room• Locomotion Outside Room• Walk in Room
• Scoring Scale– 0 – Independent/client declined– 1 – Supervision– 2 – Limited Assistance– 3 – Extensive Assistance– 4 – Total Dependence/no provider/client not able
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Reductions for Informal
Support• IADLs looked at– Self-administration of medication– Bed mobility– Walk in room– Eating– Toilet use– Dressing– Personal hygiene– Bathing– Meal Preparation– Ordinary housework– Essential shopping– Travel to medical
• Determine if IADL is unmet (1), met (0), service declined (0), or partially met (25%, 25%-50%, 50%-75%, or 75%-100%)
• Each IADL is weighted from 0 to 1 and placed in a formula to reduce hours
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Automatically Unmet Needs• Meal Preparation (special diets)
– ADA (diabetes)– Autism diet– Calorie reduction– Low sodium– Mechanically altered– Planned weight change program– Renal diet– Nutrition through tube or >25% of calories through tube/parenteral feeding
• Housework– Incontinent all or most of the time– Frequently incontinent– Occasionally incontinent
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Automatic Reductions• Client living with personal care provider
– Automatic reductions revoked– Jenkins v. DSHS, 160 Wn.2d 287 (2007); 157 P.3d 388
(Wash. 2007)• Multiple clients receiving personal care who live
in same household – met or partially met– Meal preparation– Housekeeping– Shopping– Wood supply
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Children in the CARE
Assessment• Reductions
– Some ADLs coded as met until a certain age– Most IADLs coded as met until 18– Ex. Total toileting is met up to age 3
• Living with legally responsible natural/step/adoptive parent = met or partially met (75% - 100%)
• Certain conditions cannot exist prior to particular ages– Ex. No short or long term memory loss prior to age 12– Ex. Decision making independent prior to age 12
• WAC 388-106-213• Next lawsuit?
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Add on hours• Offsite laundry +8 hours• >45 minutes from essential services (full-service market)
– +5 hours (unmet or <25% met)– +4 hours (25% - 50% met)– +2 hours (50% - 100% met)– 0 hours (met)
• Wood supply as sole source of heat– +8 hours (unmet or <25% met)– +6 hours (25% - 50% met)– +4 hours (50% - 75% met)– +2 hours (>75% met)– 0 hours (met or declined)
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Exception to Rule
• WAC 388-440• Exception to any DSHS regulation in individual cases
– Can’t contradict federal or state law– Individual’s situation differs from the majority– Interest in overall economy and individual’s welfare– Either
• Increases opportunities to function effectively• Impairment or condition significantly interferes with procedures to
determine eligibility or payment.• Only DSHS staff can submit an ETR• Can request non-covered medical or dental services or related
equipment• Increased DSHS scrutiny on ETR requests previously granted
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Right to Administrative
Hearing• Clients have a right to administrative hearing if they
disagree with the assessment.• Difficult to challenge the CARE Tool itself – focus on
application of CARE Tool to the client• WAC 388-02 governs hearings• Informal meeting with case worker or fair hearing
coordinator• Exception to Rule (ETR)
– WAC 388-106-1315 provides hearing right– Must already be receiving hours on an ETR– Total hours reduced by a reduction or termination of ETR hours– No hearing right for newly requested ETR which is denied
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Medicare• Individual eligible post age 65 or 29 months post disability. • Disabled child eligible if eligible under parents SSDI benefits• Coverage:
– Hospital– Doctor visits– Durable medical equipment– Prescription Drugs– Limited Rehab
• Co-pays, premiums and deductibles exist
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Dually Eligible
• Eligible for both Medicaid & Medicare• Primary Program is Medicare
– Hospital Visits– Doctor’s Appointments– Prescription Drug Coverage
• Medicaid supplements– Premiums & Deductibles for Hospital and Medical Insurance
may apply– Out of pocket costs– LTC– Non-Medicare Services
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Medicaid vs. Medicare
Medicaid• Eligibility similar to SSI
– Disability– “Means” tested
• Large variety of medical-related services– Residential placements– Personal care attendants– Respite care– Mental health services– Extended health care
• Department of Social & Health Services (DSHS)– Division of Developmental
Disabilities (DDD)– Aging and Adult Services
(AAS)
Medicare• Eligibility similar to
SSDI/SSA– 29 months after
disability or 65 & older– Work History
• Health Insurance– Hospitals & physicians– Limited custodial care– Prescription drugs
• U.S. Department of Health & Human Services
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DDD Overview
• Legal Authority–RCW Title 71A–WAC 388-823 to -850
• Eligibility ≠ Services• DDD is a Division of DSHS• http://www.dshs.wa.gov/ddd
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DDD Regional Map
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DDD Eligibility & Assessment
ProcessIntake & Eligibility
No
Paid
Svcs
Paid or No Paid Services?
Assessment Details Report
Service Level Assessment
Individual Support Plan
Start
Case Mgmt and
Services
Support Assessment
Paid Svcs
Case Mgmt
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DDD Services
• Case Management• Dental Services• Employment and Day Programs• Individual and Family Service Program (formerly Family Support)• Medicaid Personal Care Hours• Vocational, Employment & Educational Assistance• Early Intervention (recently moved to Department of Education)• Medically Intensive Children’s Program• Mental Health Programs• Disability-specific program, especially for autism• Living facilities
– Adult family homes– Supported Living– Host homes/companion homes– Residential Habilitation Centers (Institutions)
• Home & Community Based Waivers (HCBS)• Children’s Intensive In-Home Behavior Support Program (CIIBS)
• Voluntary Placement Program (VPP)
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Defining “Developmental
Disability”• RCW 71A.10.020(3) and WAC 388-823-0040• Disability Attributable to:
– Intellectual Disability– Cerebral Palsy– Epilepsy– Autism– Another Neurological Condition– Other Condition Related to Intellectual Disability– Other diagnosis under age 18
• Originated prior to age 18• Expected to continue indefinitely• Substantial limitations to adaptive functioning
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DDD Eligibility by Age
Eligible Condition Age 0-5
Age 6-9
Age 10-17
Age 18 and older
Developmental Delays X X
Downs Syndrome X X
Too severe to be assessed X X
Medically Intensive X X X
Mental Retardation X X X
Cerebral Palsy X X X
Epilepsy X X X
Autism X X X
Another Neurological Condition X X X
Other condition similar to MR X X X
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DDD Assessment• Broader than CARE Assessment for Medicaid Personal Care Hours• Currently does not create different hours than the CARE
Assessment– May change in the future– Assess eligibility and need for other DDD programs
• Better assessment of the needs of individuals with developmental disabilities
• Consolidates the assessment of need for services being provided through DDD
• Value of Individual Support Plan• Can take between 2 and 6 hours to complete
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DDD Assessment
• WAC 388-828• Determines each client’s individual support needs• 3 sections of DDD Assessment
– Support Assessment Module• HCBS Waiver eligibility• Determine need for other modules (those receiving or approved for paid services)• Support Intensity Scale (SIS) for 16+ (developed for DD community)• Children’s Support Needs Assessment for under 16• Exceptional Medical and Behavior Supports and Family Caregiver Needs
– Service Level Assessment Module• Assists in developing the ISP• CARE Assessment• Additional questions to determine services needed (seizure and allergy information, employment support
levels for individuals receiving county services)
– Individual Support Plan Module• Description of services client is to receive
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Support Intensity Scale• The SIS evaluates supports needed for a person in:
– 49 life activities, – 8 protection & advocacy activities, – 16 medical conditions, and – 16 problem behaviors
• Measures type, frequency, and amount of time of supports a person needs to be successful
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Individual and Family Service
Program (IFS)• Formerly Family Support• WAC 388-832• Purpose:
– Form a partnership between the state and families to help support families who have a DDD eligible family member living in the family home
– Provide families with a choice of services and allow families more control over the resources allocated to them.
• Eligibility based on need– No financial criteria– Other DDD services reduce & eliminate IFS
• $2,000 to $6,000 for therapies, respite, equipment, etc.• Access
– Waiting lists exist– Emergency funding available for up to 2 months.– One-time awards
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DDD Home & Community
Based Service (HCBS) Waivers• WAC 388-845• Alternative to institutions • Focus: remaining in homes & communities• Broad, flexible, individualized services determined through
assessment• Community placements
– Home (own or family)– Adult Family Homes– Supported Living Facility– Nursing Facility– Companion, host, and foster homes
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DDD HCBS Waivers
• Types of Waivers– Basic– Basic Plus– CORE– Community Protection– Children’s Intensive In-Home Behavior Support Program (CIIBS)
• Eligibility– Eligible for DDD services– ICF/MR level of care– SSA disability– Financial eligibility
• Types of services and money available depend on the type of Waiver• “In the database” vs. “receiving the waiver”
– Priority may be given to “Persons DDD has determined to be in immediate risk of ICF/MR admission due to unmet health and welfare needs.” WAC 388-845-0045(2)(b)
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HCBS Waiver Services
• Case management• Respite care• Behavior management & intervention• Community access and involvement (guides, work, transportation)• Mental health services• Skilled nursing• Family & staff training• Speech & language services• Occupational & physical therapy• Personal care services• Dental Care• Habilitation services• Medical & Adaptive supplies• Emergency Services
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CIIBS Waivers
• RCW 71A.24; WAC 388-828-8500 to -8520 (emergency rule)• Focus on:
– Behavior Support– Staff and Family Training and Consultation– Respite Care
• Contract with behavior support specialist• Positive Behavior Support Plan• 100 Children initially + 6 each month• Priority/eligibility based on out-of-home risk score through CIIBS Algorithm (data collected in DDD
Assessment)• Other services may include:
– Personal Care– Specialized Nutrition and clothing– Therapeutic Equipment and Supplies– Environmental Accessibility Adaptations– Vehicle Adaptations– Specialized Medical Equipment and Supplies– Assistive Technology
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Administrative Hearing
Process• RCW 34.05.410 - .598 and WAC 388-02• Process
– Planned Action Notice– Request for hearing– Pre-hearing conference call– Administrative Hearing before an independent ALJ with OAH– DSHS Appeals Council– Petition for Review before Superior Court– WA Court of Appeals– WA Supreme Court– US Supreme Court (if federal issue exists)
• Exception to Rule (ETR)– Hearing rights for reduction or termination of DDD services only.– “No hearing right” for newly requested ETR which is denied.
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Other Public Benefits
• Income/Asset Sensitive Vocational Rehabilitation Housing and Urban
Development (HUD) Programs
Temporary Assistance for Needy Families (TANF)
General Assistance (GA) Food Stamps State/County specific
programs Early Childhood
Development (EPSDT) Insurance Alternatives
(CHIPs)
• Non-Income/Asset Sensitive Special Education Some Medicaid Waiver
Programs Community/Church
programs Generic Recreational
Programs (i.e. Park Department, Special/Para/Quad Olympics)
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Disclaimer/Notice• This training and written materials are designed to
provide accurate and authoritative information in regard to the subject matter covered. It is provided with the understanding that the presenter is not engaged in rendering legal, financial or other professional services. If legal advice or other expert assistance is required, the services of a competent professional should be sought.
• Please keep in mind all written materials and power point slides are the intellectual property of the Dussault Law Group. These materials may not be distributed without the express written consent of the authors.
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Thank You!
Joshua L. BrothersDussault Law Group
(206) 324-4300E-mail: [email protected]
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