SUPERIOR COURT OF {CASESTATE}
COUNTY OF {CASECOUNTY}

In the Estate of {DPName}, a Disabled Person	No. {CaseNum}

AFFIDAVIT IN SUPPORT OF NEED FOR CREATION OF
AN OBRA ’93 SPECIAL-NEEDS TRUST

AFFIDAVIT OF {AFFNAME}

I, {AffName}, under penalties of perjury, state the following:

My name is {AffName}, and I am employed by {ResidName} as {AffTitle}.

{DPName} has been a resident of {ResidName} since {ResidStartDate}.

As {AffTitle} of {ResidName}, I see {DPName} {AffFrequency}.

{DPName} suffers from {DPDisability}.

Currently, {DPName} is participating in {ResidParticip}.

{DPName}’s prognosis for recovery to a point at which {he|she} would be able to maintain gainful employment is unlikely.

{ResidBehav}{.}

{DPName} demonstrates deficits in cognition and judgment that make {him|her} incapable of managing {his|her} personal and financial affairs.

I am of the opinion, based on my involvement in the life of {DPName}, that it is unlikely {he|she} will be restored by the Court because of {his|her} inability to handle {his|her} personal and financial affairs. I believe that {DPName} will not be able to live independently.

During {DPName}’s life, {he|she} will need funds available for services and general care that will not be paid by {his|her} benefits. {ResidNeeds}{.}

In my opinion, it is in the best interests of {DPName} for this Court to grant leave to {GrdName} to create a sub-account in a special-needs pooled trust on behalf of {DPName} to shelter {his|her} funds.

_______________________________________

{AFFNAME}

Signed and sworn to before me this

_____ day of _____________, 20__.

______________________________

Notary Public

{AttyName}, {Attynotype} #{AttyARDC}

{FirmName}

{FirmInfo}

TheFormTool (c) 2011-2016 Snapdone, Inc.
Label	Question	Answer
AttyName	Name of attorney	[??]
AttyARDC	Attorney’s Number	[??]
AttyNoType	Type of Attorney’s Number Examples: ARDC, WSBA, etc.	[??]
FirmName	Name of law firm	[??]
FirmInfo	Firm’s address, phone, website, etc.	[??]
Case
CaseNum	Case number	[??]
CaseCounty	County	[??]
CaseState	State	[??]
Disabled Person
DPName	Name	[??] [??]
DPDisability	Disability Example: dementia	[??]
Guardian
GrdName	Name	[??] [??]
Residential Facility
ResidName	Name of residential facility	[??]
AffName	Name of affiant	[??]
AffTitle	Title of affiant	[??]
ResidStartDate	Date Disabled Person moved into residential facility Format: m/d/yyyy	[??]
AffFrequency	How frequently does affiant see Disabled Person?	[??]
ResidParticip	“Disabled Person currently participates in __________.” List rehab programs, workshops, etc.	[??]
ResidBehav	Provide statement about Disabled Person’s social, adaptive & behavioral skills. Use full sentences	[??]
ResidNeeds	Provide statement describing specific needs not covered by public benefits Use full sentences	[??]