GCT of BDI Vehicle Purchase Request Form

GCT of BDI Vehicle Purchase Request Form

***DO NOT TAKE POSSESSION OF THE VEHICLE BEFORE APPROVAL FROM GCT of BDI***

Any purchase of a vehicle must be pre-approved by the Trust Administrator. Please do not take possession of a vehicle until the trust administrator has approved the vehicle purchase and issued payment for the vehicle.

Please allow up to 10 business days for processing.

Incomplete forms will be returned to the Advisory Co-Trustee.

Vehicle purchases are for the sole benefit of the beneficiary.

GCT of BDI has the right to decline the purchase of any vehicles utilizing Special Needs Trust funds.

The following application must be completed.

DO NOT TAKE POSSESSION OF THE VEHICLE BEFORE APPROVAL FROM GCT of BDI

GCT of BDI is not responsible for the purchase of a vehicle prior to the approval of the Vehicle Purchase Request Form.

Person Making Request

Verification of Authorization to Request Funds*

I am authorized to make requests on behalf of the Beneficiary.

By checking below, I do hereby attest that I am authorized to make requests on behalf of the Beneficiary and that the information below is true, accurate and complete to the best of my knowledge and I understand that falsification, omission, or concealment of this information may subject the beneficiary to loss of SSI/Medicaid, and/or payback of funds to the beneficiary’s sub-account.

Yes, I am authorized to make purchases (My Name is Listed on the Joinder Agreement)

No, I am not authorized to make purchases (My Name is NOT Listed on the Joinder Agreement)

Unknown, I am not sure if I am authorized to make purchases.

Signature*

Please type your full name below.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

If you are not the Advisory Co-Trustee please enter the Advisory Co-Trustee Name below:*

Vehicle Purchases

***DO NOT TAKE POSSESSION OF THE VEHICLE BEFORE APPROVAL FROM GCT of BDI***

Please allow up to 10 business days for processing. Incomplete forms will be returned to the Advisory Co-Trustee.

Vehicle purchases are for the sole benefit of the beneficiary.

GCT of BDI has the right to decline the purchase of any vehicles utilizing Special Needs Trust funds.

Beneficiary Sole Benefit Acknowledgement*

Please note vehicle purchase utilizing Special Needs Trust funds are intended to be used for the Sole Benefit of the Beneficiary.

Please type your name below verifying that you acknowledge that the purchase of this vehicle is for the Sole Benefit of the Beneficiary and that the vehicle will not be used for any other purpose than to provide transportation for the beneficiary and/or make purchases or pay bills on behalf of the beneficiary. Please contact GCT of BDI if you have any questions.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Beneficiary Information

Beneficiary Name*

SSI Recipient*

Yes

Medicaid Recipient*

Yes

Medicaid Waiver Recipient*

Beneficiary Living Arrangements*

Alone (house/apartment)

with Family

Host Home/Group Home

Institution/Nursing Home

Update Contact Information*

Yes

Email Address

Address

City

State

Zip Code

Phone Number

Phone

Please answer the questions below:

Do you already own a vehicle?*

Yes

Are you planning on trading in your current vehicle?*

Yes

Are you planning to purchase a vehicle from an individual, Craigslist or other classified ad?*

Yes

I understand all vehicle purchases are subject to the approval of GCT of BDI? GCT of BDI will not approve the purchase of luxury vehicles.*

Yes

I acknowledge that the vehicle must be titled or co-titled in the beneficiary’s name.*

Yes

I acknowledge that GCT of BDI will place a lien on the title of the vehicle.*

Yes

One Vehicle Limit Acknowledgement*

Please note that the Social Security Administration and Medicaid only allows one automobile per household.

For Supplemental Security Income (SSI) and Medicaid purposes, “automobile” means any registered or unregistered vehicle used for transportation. Vehicles used for transportation include but are not limited to cars, trucks, motorcycles, boats, recreational vehicles (RVs), all terrain vehicles, (ATVs), snowmobiles, and even animal-drawn vehicles.

Please type your name below verifying that you acknowledge Social Security Guidelines, only allowing one vehicle per household.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

I agree to comply with state regulations, keep the vehicle registered and inspected yearly and forward proof of insurance to the GCT of BDI?*

Yes

I agree to upload a copy of the Vehicle History Report for the purchase of a pre‐owned vehicle.*

Yes

I agree to upload a copy of the the vehicle invoice from from the dealership.*

Please check below that you have uploaded a copy of the vehicle invoice with total cost of the vehicle included.

Yes

Driver Information

Is the beneficiary (trust account holder) the primary driver of this vehicle?*

Yes

Please type the full name of the Primary Driver below:*

Please select the relationship of Purchaser to the beneficiary.*

Parent

Legal Guardian

Family Member

Other

Does the Primary Driver live in the same home as the Beneficiary?*

Yes

Is this vehicle for a beneficiary (trust account holder) that is a minor?*

Yes

Please enter the state that issued the Primary Driver's License below:*

Please enter the Primary Driver's License Number below:*

Please enter the number of individuals living in the household below:*

Please enter the full name of any Secondary Driver below:, if applicable:

Please enter the state that issued the Seconday Driver's License below:

Please enter the Secondary Driver's License Number below:

Provide a copy of the all identified Driver's Licenses.*

Please check below that you have uploaded a copy of the purchaser's valid driver's license.

Yes

Vehicle Information

Vehicle VIN Number:*

Make (Chevy, Ford, etc.): *

Model (Malibu, Focus, etc.):*

Vehicle Year*

Vehicle Color*

Vehicle Mileage*

Vehicle Purchase Price*

Will the vehicle require accomodations for the beneficiary?*

Yes

Please enter the estimated costs of the vehicle modifications below:

Seller Information

Dealership: *

Sales Person Name:*

Sales Person's Email:*

Dealership Phone Number:*

Dealership Address:*

Please list street, city, state, and zip code.

Insurance Information

GCT of BDI FBO "Beneficiary Name" must be listed as a loss payee/lien holder on the policy.

Insurance Company

Insurance Policy Number

Please enter the estimated insurance amount below:

What is the frequency of the insurance billing:

Monthly

Every 6 month

Annually

Do you expect the beneficary trust funds to cover the costs of insurance?*

Yes

Vehicle Payment Information

Vehicle Payment Type*

How would you like the payment for the vehicle to be made? All payments will be made directly to the Merchant.

Check

Direct Deposit (ACH)/Wire

Check Payment Information

Merchant Name*

Bill Pay Address*

Bill Pay City*

Bill Pay State

Bill Pay Zip Code*

ACH Direct Deposit or Wire Payment Information

Account Owner Name*

Bank Name*

Bank Address*

Bank City*

Bank State *

Bank Zip Code*

Bank Routing Number*

Bank Account Number*

SWIFT Code

Wire Instructions

File Upload*

File Checklist:

Vehicle History Report
Vehicle Invoice or Bill of Sale
A copy of all Driver licenses
Insurance Information (if applicable)

Drag and drop files here or

PLEASE CONTACT GCT OF BDI

There appears to be an issue with your request to purchase a vehicle. Please contact a member of the GCT of BDI Team at 678-365-0071 to discuss next steps. Thank you.

Signature

Purchase/Negative Pledge Agreement*

I (Beneficiary or Advisory Co-Trustee) (“Borrower”) have requested the use of the Beneficiary’s Special Needs Trust funds (“Lender”) in the amount listed above for the purchase of a motor vehicle (“Security”). Borrower agrees that GCT of BDI (“Secured Party”) will place a lien on the motor vehicle on behalf of the Lender.

Borrower agrees that the motor vehicle is for the sole benefit of the Beneficiary and will be used for the transportation of the Beneficiary or used in the capacity to meet the support needs of the Beneficiary. Borrower agrees that any use of the motor vehicle that is not specifically for the sole benefit of the Beneficiary could result in Secured Party taking all remedies provided by law to obtain procession of the vehicle including foreclose the lien, taking physical possession of the motor vehicle, and in necessary liquidation of motor vehicle to fully cure and repay the principal purchase price of the vehicle to the Lender.

Borrower agrees that the in using Special Needs Trust funds for the purchase of a motor vehicle may retain the physical possession, ownership, and use of the motor vehicle. However, Borrower agrees to not sell, gift, or relinquish possession of the motor vehicle without the consent of the Secured Party. In the event that, the motor vehicle is to be sold or traded for another motor vehicle Borrower agrees to obtain advanced approval from Secured Party, and that any funds in excess of the trade value will be directed to GCT of BDI for the benefit of (FBO) the Beneficiary. In the event that, the motor vehicle is in an accident and considered a total loss by the insurance company Borrower agrees all payments will be directed to GCT of BDI for the benefit of (FBO) the Beneficiary.

Borrower agrees that if the Beneficiary’s Special Needs Trust maintains a Medicaid Payback Provision (1st Party Account) that upon the death of the Beneficiary that the vehicle must be liquidated, and the total amount of the liquidated amount must be directed to GCT of BDI for the benefit of (FBO) the Beneficiary. Borrower agrees that if Secured Party must take any steps to foreclose the lien, take physical possession of the motor vehicle, and if necessary liquidation of motor vehicle, that the Beneficiary’s Special Needs Trust will be responsible for the ancillary expenses regarding the aforementioned steps, including additional Trust Administration Fees.

Please type your full name below.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Promissory Note

I (Beneficiary or Advisory Co-Trustee) resident of the State of Georgia promises to pay back to the order of GCT of BDI fbo Beneficiary Name (“Payee”), the principal sum of the total of the vehicle purchase price or assessed value, purchased on ______ (“Purchase Date”) in the amount of _________ (“Principal Sum”). The entire unpaid Principal Sum balance or assessed value shall be payable in full to the Payee in the event of the following conditions:

1. The motor vehicle is no longer being used for the sole benefit of the Beneficiary.

2. The motor vehicle is sold, traded, or liquidated.

3. Death of the Beneficiary.

Please type your full name below.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Security Agreement

You (Beneficiary or Advisory Co-Trustee) to secure repayment of the Principle Sum evidence by the Promissory Note above, do grant GCT of BDI (“Secured Party”), pursuant to the laws of the State of Georgia, a Security Interest In and a lien upon the motor vehicle (“Security”) set forth above, and all accessions thereto, and all proceeds thereof which act as Security for the full repayment of the sums advanced by the Beneficiary’s Special Needs Trust funds pursuant to the Purchase/Negative Pledge Agreement and the Promissory Note.

You have further granted GCT of BDI on behalf of the Beneficiary’s Special Needs Trust account, as security under the Georgia Code of Laws, as assignment and security interest in all proceeds of insurance or refunds of unearned premiums, or both respecting any and all policies of insurance assuring against the loss and/or total destruction for the collateral to assure your repayment of the monetary sum provided by the Beneficiary’s Special Needs Trust funds. At all times that monetary sums remain due and unpaid, the security shall not be removed from the State of Georgia.

By this Security Agreement, you hereby expressly grant to GCT of BDI, as Secured Party, in the event of default pursuant to the Promissory Note or any of the terms and conditions of the Purchase/Negative Pledge Agreement, and irrevocable right of Secured Party to physically repossess the Security to allow foreclosure upon Secured Party’s lien. In the event of such repossession, you hereby expressly gran to Secured Party the absolute right to liquidate the Security and upon liquidation, you may not receive all excess proceeds of liquidation after deduction for full payment to Beneficiary’s Special Needs Trust account of the principal amount due pursuant to the Promissory Note and foreclosure costs of public sale including all costs and fees to the extent provided by lay and incurred by the Secured Party.

You further grant Secured Party your Power-of-Attorney-in-Fact to allow Secured Party full authority to perfect its lien upon title to the Security with the State of Georgia Department of Motor Vehicles. You expressly warrant and promise that until such time as the Principal Sum has been fully repaid you will not attempt to or seek to obtain a duplicate title to the Security which you continue to own. You will at all times the Principal Sum is outstanding and until a foreclosure upon the Secured Party’s lien, be the legal owner of the motor vehicle pursuant to the laws of Georgia.

Please type your full name below.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Acknowledgments*

By signing below the signatory certifies the following:

I acknowledge that I will not take possession of the vehicle without GCT of BDI's approval. I understand that if I take possession of the vehicle without prior approval that the Beneficiary's trust is not responsible for costs associated with the purchase of the vehicle.

I acknowledge that the vehicle will be be for the sole benefit of the beneficiary.

I acknowledge that the vehicle must remain available for the beneficiaries use at all times. I acknowledge that any denial of usage of the vehicle to the beneficiary may result in the repossession or liquidation of the vehicle.

I acknowledge that the GCT of BDI will place a lien on title of the vehicle.

I acknowledge that GCT of BDI has the final approval of all vehicle purchases.

I acknowledge that SSI and Medicaid only allows for one (1) vehicle per household.

By checking below, I do hereby acknowledge the above

list of items and I understand that falsification, omission, or concealment of information may subject the beneficiary to loss of SSI/Medicaid, and/or payback of funds to the beneficiary’s sub-account.

Signature*

Please type your full name below.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Requester Email Address*

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