third-party pooled special needs trust joinder agreement€¦ · 03/2018 page 1 of 13 third-party...

03/2018 of 13

Third-Party Pooled Special Needs Trust Joinder Agreement

Trust Adoption Instrument Tax Identification Number 54-6302655

The undersigned Grantor(s) hereby irrevocably establish(es) a trust fund (sub account) under Commonwealth Community Trust Third-Party Pooled Special Needs Trust Master Trust Agreement (MTA), established by Commonwealth Community Trust (CCT), a non-profit, non-stock Virginia Corporation. The terms of the Grantor’s trust fund are set forth in this Joinder Agreement (Joinder) and the applicable provisions of the MTA, as amended and restated, which is hereby adopted and incorporated herein by reference hereto. The terms of this Joinder may be revised in accordance to the MTA and such revisions shall relate back to the date hereof.

This is a binding legal document. You are advised to seek professional advice before signing.

1. Grantor(s) Information:A. Grantor 1:

Mr. Mrs. Ms.

Address:

City: State: Zip:

Home Phone: Work Phone:

Cell Phone: Email Address:

Relationship to Beneficiary:

B. Grantor 2 (if applicable):

Mr. Mrs. Ms.

Address:

City: State: Zip:




2. Beneficiary Information:

Mr. Mrs. Ms.

Address:

City: State: Zip:

Type of Residence: (e.g. private residence, group home)

Home Phone: Cell Phone:

Email Address:

3. Beneficiary Date of Birth:

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4. Beneficiary Social Security Number*:

*A copy is requested.

5. Description of Beneficiary’s Disability: Please provide written documentation from a medical professional.

Primary Diagnosis:

Secondary Diagnosis:

Additional Information:

6. Designation of Advocate: Once the trust is funded, the Advocate is the person(s) responsible (*e.g., parent, sibling, relative, Guardian, Representative Payee, Power of Attorney, Beneficiary, Caseworker, Conservator, or other) for requesting disbursements and communicating information about the Beneficiary and the Trust.

PLEASE IDENTIFY PRIMARY ADVOCATE(S).

A. Primary Advocate(s): This person or person(s) receives financial account information, tax documents and official correspondence from CCT and signs disbursement requests.

1.) Primary Advocate 1:

Mr. Mrs. Ms. Last 4 Digits of SSN:

Address:

City: State: Zip:

Cell Phone: Home Phone:

Email Address: Work Phone:

*Relationship to Beneficiary:

Indicate account access preference: ☐Online / Internet ☐Mail

*Provide CCT with legal documentation for Guardianship, Power of Attorney, and/or Conservator.

2.) Primary Advocate 2:


Address:

City: State: Zip:




Indicate account access preference: ☐Online / Internet ☐Mail

*Provide CCT with legal documentation for Guardianship, Power of Attorney, and/or Conservator.

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PLEASE IDENTIFY AT LEAST ONE SECONDARY ADVOCATE IF ONLY ONE PRIMARY ADVOCATE IS NAMED. The Secondary Advocate will be contacted if the Primary Advocate cannot be reached or to obtain additional information.

B. Secondary Advocate: This person or person(s) can receive financial account information, can sign disbursement requests and will be contacted by CCT when needed.

1.) Secondary Advocate 1:


Address:

City: State: Zip:




Permission to receive financial account information?

a) Immediately upon funding? ☐ YES ☐ NO

b) If requested in the future? ☐ YES ☐ NO

If YES to a) or b), indicate account access preference:

☐Online / Internet ☐Mail

Provide CCT with legal documentation for Guardianship, Power of Attorney, and/or Conservator.

2.) Secondary Advocate 2:


Address:

City: State: Zip:




Permission to receive financial account information?

a) Immediately upon funding? ☐ YES ☐ NO

b) If requested in the future? ☐ YES ☐ NO

If YES to a) or b), indicate account access preference:

☐Online / Internet ☐Mail

Provide CCT with legal documentation for Guardianship, Power of Attorney, and/or Conservator.

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7. Additional Contacts: In addition to the Primary and Secondary Advocates, permission is granted to contactand share information with the following should the need arise (optional):

A. Additional Contact 1:

Mr. Mrs. Ms.

Address:

City: State: Zip:




B. Additional Contact 2:

Mr. Mrs. Ms.

Address:

City: State: Zip:




8. Revocability of Trust (check one of the following options):

☐ (a) The trust fund cannot be revoked.

☐ (b) The trust fund can be revoked so long as individual Grantor lives.*

☐ (c) The trust fund can be revoked so long as any Grantor lives (where there is more than one Grantor).*

☐ (d) The trust fund cannot be revoked after the death of any one Grantor (where there is more than one Grantor).*

Note: Any revocation must be made by all living Grantors, in writing, properly notarized, and in a form acceptable to the Trustee.

*Notwithstanding the foregoing, in the event that the trust fund receives any assets prior to the death(s) ofthe Grantor(s), the trust fund shall become irrevocable to the extent funded and the Grantor(s) and/or any donors to the trust fund shall not have the right to alter, amend, revoke or terminate the trust fund with respect to the donated funds. In such an event, the Grantor(s)’ election above with respect to the revocability of the trust fund shall continue in force with respect to all other aspects of the trust fund and this Joinder Agreement and the Grantor(s) and third parties shall be entitled to add additional property to the Trust Fund.

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9. Beneficiary’s Funeral or Burial Arrangements:

A. Have pre-need funeral arrangements been made/paid for the Beneficiary?

☐ Yes ☐ No

B. If yes, provide the following information, if available.

Insurer/Other:

Name of Contact:

Policy #:

Phone:

Email Address:

C. If no, do you anticipate using funds from the trust to pay for pre-need arrangements? ☐ Yes ☐ No

Note: Any arrangements must be paid pre-need. Upon death of the Beneficiary, any remaining funds will be distributed according to Section 12 Distributions of the Remainder Funds Upon the Death of the Beneficiary of this Agreement.

10. The Grantor(s) agrees to the current published fee schedule as may be amended from time to time.IMPORTANT NOTE: CCT may, from time to time and at its discretion, hire additional professionals to serve as a liaison between CCT and the Beneficiary, or to assess the financial or custodial care arrangements of the Beneficiary and provide reports to CCT (e.g. accountants, attorneys, health care professionals, social workers, life care planners, and care managers). CCT reserves the right to charge this expense to the Beneficiary’s trust account.

11. Government Assistance the Beneficiary Receives: CCT will provide information to local governmentagencies for SSI, Medicaid, food stamps and subsidized housing recipients.

A. Social Security Information:

Does Beneficiary receive Supplemental Security Income (SSI): ☐ Yes ☐ No ☐ Applying

Does Beneficiary receive Supplemental Security Disability Insurance (SSDI): ☐ Yes ☐ No ☐ Applying If yes, or in the process of applying, include contact information for local Social Security Administration Office, and a copy of Benefits Verification (Can be obtained from MYSSA.gov or by calling 800-772-1213).

If Beneficiary does not receive SSI or SSDI, please explain source of income, if any:

Agency:

Contact Name (If Applicable):

Address:

City: State: Zip:

Phone Number: Phone Ext:

Other:

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B. Medical Information:

Does Beneficiary receive Medicaid benefits? ☐ Yes ☐ No ☐ Applying

Does Beneficiary receive Medicaid Waiver benefits? ☐ Yes ☐ No ☐ Applying If yes, include contact information for local Medicaid (DSS) Office, and a copy of Medicaid eligibility letter or Medicaid card.

Agency:


Address:

City: State: Zip:

Phone Number: Phone Ext:

Does Beneficiary receive Medicare benefits? ☐ Yes ☐ No

Does Beneficiary receive any other medical benefits? ☐ Yes ☐ No

If yes, please describe:

C. Case Management or Other Support Services: Provide the following information if applicable:

Agency/Provider:

Contact Name:

Address:

City: State: Zip:

Main Phone Number: Cell Number:

Email Address:

Description of Service:

D. Section 8 or Subsidized Housing: ☐ Yes ☐ No

Agency:


Address:

City: State: Zip:

Phone Number: Email Address:

E. Other Public Assistance (e.g., food stamps):

Agency:


Address:

City: State: Zip:

Phone Number: Email Address:

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12. Distributions of the Remainder Funds Upon the Death of the Beneficiary: Upon the actual death of theBeneficiary, the trust will be restricted and any remaining and unpaid funds shall be distributed to thefollowing individuals who are then living or entities which are then in existence.

Instructions It is required that at least one Successor Beneficiary be named (See Page 8, Section 12A).

If a Successor Beneficiary is no longer living at the death of the Beneficiary, his or her share shall be distributed to the named Contingent Beneficiary (ies).

Additional Successor Beneficiaries and Contingent Beneficiaries can be added prior to funding the subaccount. (See Page 9, Section 12B and Page 10, Section 12C).

An individual or charity can be named as a Successor Beneficiary and/or Contingent Beneficiary. Naming CCT as a Successor Beneficiary and/or Contingent Beneficiary, supports the organization’s mission to serve people with special needs.

If an individual Successor Beneficiary predeceases the Beneficiary, or an entity named as a Successor Beneficiary is no longer in existence, and there is no Contingent Beneficiary named, the distribution to that individual or entity lapses and will be divided among the remaining Successor Beneficiaries who are then living or in existence.

If an individual Contingent Beneficiary predeceases the Beneficiary, or an entity named as a Contingent Beneficiary is no longer in existence, the distribution to that individual or entity lapses and will be divided among the remaining Contingent Beneficiaries to that Successor Beneficiary who are then living or in existence.

If there are no Contingent Beneficiaries then living or in existence, such remaining funds shall be distributed to Commonwealth Community Trust.

Note: The Grantor(s) can complete the Amendment to Third-Party Pooled Special Needs Trust Joinder Agreement Form to change Successor Beneficiaries and/or Contingent Beneficiaries (must be completed, signed, and notarized).

Important: The Grantor agrees that CCT is limited to make payments to the Beneficiaries under this Section known to CCT based upon the information listed in this Joinder Agreement. Grantor agrees to hold CCT harmless with respect to payment hereunder. The determination of CCT regarding payment under this Section shall be final and binding on all parties. Primary Beneficiaries and Contingent Beneficiaries and contact information for all Beneficiaries must be clearly listed. A separate piece of paper may be attached for additional Beneficiaries or to craft a scheme of distribution to fit any individual needs. Please do NOT list the “Grantor’s Estate” or “Heirs at law.” Changes can be made by the Grantor(s) prior to funding the subaccount by completing the Amendment to the Joinder Agreement Form.

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A. Successor Beneficiary A* (Required):

Name(s) SSN(s)

, or survivor

Address Home Phone

City State Zip Work Phone

Email Address

Cell Phone

Percentage A

%

If more than one Successor Beneficiary is named, the total of all Successor Beneficiaries must equal 100%. (See Page 10, Section 12D.) (required)

A1. Contingent Beneficiary to Successor Beneficiary A:

Name SSN Percentage A1 %

Address City State Zip

Home Phone Work Phone

Cell Phone Email Address











Total Percentage for ALL Contingent Beneficiary(ies) to Successor Beneficiary A

(must total 100%) %

Provide an attachment with additional Successor Beneficiaries and Contingent Beneficiaries, if desired.

*If Successor Beneficiary A is no longer living at the death of the Beneficiary, his or her share shall be distributed to the following Contingent Beneficiary(ies).

Example: A1: 25% + A2: 25% + A3: 50% = 100%

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B. Successor Beneficiary B*:

Name(s) SSN(s)

, or survivor

Address Home Phone


Email Cell Phone Address

Percentage B

%


B1. Contingent Beneficiary to Successor Beneficiary B:

Name SSN Percentage B1 %














Total Percentage for ALL Contingent Beneficiary(ies) to Successor Beneficiary B

(must total 100%) %


*If Successor Beneficiary B is no longer living at the death of the Beneficiary, his or her shareshall be distributed to the following Contingent Beneficiary(ies).

Example: B1: 25% + B2: 25% + B3: 50% = 100%

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C. Successor Beneficiary C*:

Name(s) SSN(s)

, or survivor

Address Home Phone


Email Cell Phone Address

Percentage C

%


C1. Contingent Beneficiary to Successor Beneficiary C:

Name SSN Percentage C1 %




C2. Contingent Beneficiary to Successor Beneficiary C:

Name SSN Percentage C2 %




Total Percentage for ALL Contingent Beneficiary(ies) to Successor Beneficiary C

(must total 100%) %


D. Summary (required if more than one Successor Beneficiary is named):

Name of Successor Beneficiary A: Percentage A %

Name of Successor Beneficiary B: Percentage B %

Name of Successor Beneficiary C: Percentage C %

Total Percentage for ALL Successor Beneficiaries (must total 100%) %

*If Successor Beneficiary C is no longer living at the death of the Beneficiary, his or her shareshall be distributed to the following Contingent Beneficiary(ies):

Example: C1: 50% + C2: 50% = 100%

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13. Funding Information: IMPORTANT NOTE: All assets intended for the Beneficiary must be third-party assets, typically belonging to

the Grantor, family member, or friend at the time of transfer.

A. How will this sub account be funded? (Please check any that apply.)

☐ Lifetime contribution(s) by Grantor(s) or others

☐ Transfer from an existing Special Needs Trust - Please provide copy of trust.

☐ Last Will and Testament of the Grantor(s) - Please provide copy of will.

☐ Life Insurance Policy of the Grantor(s) - Please provide copy of the policy.

☐ Revocable Living Trust - Please provide copy of the trust.

☐ Other (please explain):

B. Amount to be deposited into the trust (estimate if not certain): $

C. Will qualification of the Trustee before the Clerk of Court and/or annual filings with the Commissioner of

Accounts be required by the Court? ☐ Yes ☐ No If yes, please provide a copy of the order.

D. Will there be a Court ordered settlement? ☐ Yes ☐ No If yes, please provide a copy of the proposed order, and the entered order after the hearing.

14. Please read the following:

A. In order to facilitate pooling of the assets in all sub accounts, it is required that all deposits must be made in cash. The trust does not hold non-cash assets or real estate property.

B. Income and principal will be distributed for the Beneficiary at the sole discretion of CCT.

C. The provisions of this Joinder Agreement may be amended as determined reasonably necessary by CCT so long as any such amendment is consistent with the Master Trust Agreement or is deemed necessary to conform to any changes required by the law.

D. It is understood and agreed upon that the trust is for the sole benefit of the Beneficiary.

E. Trustee and other fees shall be charged in accordance with the Fee Schedule as amended from time to time. NOTE: CCT may, from time to time and at its discretion, hire additional professionals to serve as a liaison between CCT and the Beneficiary, or to assess the financial or custodial care arrangements of the Beneficiary and provide reports to CCT (e.g. accountants, attorneys, health care professionals, social workers, life care planners, care managers). CCT reserves the right to charge this expense to the Beneficiary’s trust sub account.

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F. Taxes (1 The Grantor acknowledges that there have been no representations made to the Grantor regarding

the deductibility of the contributions to the trust as charitable gifts or otherwise. (2 Trust fund (sub account) income, whether paid in cash or distribution in other property may be

taxable to the Beneficiary, subject to applicable exemptions and deductions. Professional tax advice is recommended.

(3 Income of the trust fund (sub account) may be taxable to the trust and when this occurs, such taxes shall be payable from the trust fund (sub account) of the Beneficiary.

G. This trust administered by CCT is a pooled trust, governed by the laws of Virginia, in conformity with the

provisions of 42 U.S.C. § 1396p, amended August 10, 1993, by the Revenue Reconciliation Act of 1993. To the extent there is conflict between the terms of the Trust Agreement and/or this Instrument, and the governing law as from time to time as amended, the law and regulations shall control.

15. Professional Representation: The Grantor(s) has/have been represented with regard to CCT by:

Name:

Firm:

Address:

City: State: Zip:

Phone: Email Address:

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THIS JOINDER AGREEMENT NEEDS TO BE SIGNED IN FRONT OF A NOTARY. PROVIDE ORIGINAL JOINDER AGREEMENT WITH W-9 FORMS TO CCT.

16. In Witness Whereof – The undersigned Grantor(s) has/have signed this agreement and understand(s) same

and agree(s) to be bound by the terms thereof this ________ day of _____________________, 20_____. ________________________________________ __________________________________________ Grantor’s Signature Grantor’s Signature STATE OF________________________________ CITY/COUNTY OF________________________________ TO-WIT: The foregoing Joinder Agreement, dated __________________________ was acknowledged before me by ____________________________________ and ______________________________________, Grantor(s), this ________ day of _____________________, 20_____. _______________________________________ My commission expires: _____________________________ Notary Public

TO BE COMPLETED BY COMMONWEALTH COMMUNITY TRUST (CCT): Commonwealth Community Trust hereby accepts the terms of this Joinder Agreement on this ______ day of __________________, 20_____. By _____________________________________________ Title: _____________________________________ STATE OF VIRGINIA, COUNTY OF HENRICO TO-WIT: The foregoing Joinder Agreement, dated ________________________ was acknowledged before me by ____________________________________on behalf of CCT, this _____ day of__________________ , 20 ____ . _______________________________________ My commission expires: _____________________________ Notary Public

Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

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2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal RevenueService (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

COMPLETE HIGHLIGHTED SECTIONS FOR THE BENEFICIARY.

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Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Pri

nt o

r ty

pe

See

Sp

ecifi

c In

stru

ctio

ns o

n p

age

2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal RevenueService (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

COMPLETE HIGHLIGHTED SECTIONS FOR GRANTOR.

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third-party pooled special needs trust joinder agreement€¦ · 03/2018 page 1 of 13 third-party...

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