GCT of BDI Change of Information

GCT of BDI Change of Information

Beneficiary Information

Beneficiary First Name*

Beneficiary Last Name*

Please enter the name of the person making the above change or request:*

Please enter the email address of the person making the above change or request:*

Type of Change Requesting*

Beneficiary Address/Phone/Email

Beneficiary Benefit Changes

Advisory Co-Trustee Address/Phone/Email

Change of Advisory Co-Trustee

Remove Advisory Co-Trustee

Change of Bank Account Information

Change in Remainder Beneficiary Information

Advisory Co-Trustee Resignation Form

Benefit Changes

Please check below if there has been any change to the Beneficiaries benefits. Please upload a copy of any benefit change notifications received.

Have you received any information that your Social Security benefits will be reduced or terminated?*

Yes

Have you received any information that your Medicaid benefits will be reduced or terminated?*

Yes

Please select any and all other benefits that are experiencing any changes.

Select or enter value

Case Manager Information

Please provide the case manager or contact information below regarding any change or new application for benefits.

Case Manager Contact Information

Case Manager Phone Number

Phone

Case Manager Email Address

Change of Physical Address, Phone Number or Email

Request to Change Advisory Co-Trustee

Please note that submission of this form does not constitute a change.

Process to change an Advisory Co-Trustee

Step 1: Complete the Request to Change Advisory Co-Trustee information below. If Conservator, Guardian, or Power of Attorney, please submit supporting documentation.

Step 2: GCT of BDI will reach out to the requested new Advisory Co-Trustee to request additional information and complete the Change of Advisory Co-Trustee Form.

Step 3: The new Advisory Co-Trustee will be required to sign and have notarized the Change of Advisory Co-Trustee Form.

Step 4: The new Advisory Co-Trustee will sign and have notarized the Advisory Roles and Responsibilities Form.

Please allow up to 30 days to complete the change of Advisory Co-Trustee process.

Request to Remove Advisory Co-Trustee

Please note that submission of this form does not constitute a change.

Process to change an Advisory Co-Trustee

Step 1: Complete the Request to Remove an Advisory Co-Trustee information below.

Step 2: GCT of BDI will reach out to you for more information.

Please allow up to 30 days to review the request to remove an Advisory Co-Trustee.

Current Advisory Co-Trustee Name*

New Advisory Co-Trustee Name*

Please list the Name (first and last) of the Remainder Beneficiary 1:

Please enter the email of the Remainder Beneficiary 1:

Please enter the Address of the Remainder Beneficiary (street, city, state, and zip)

Please enter the percentage (%) amount your would like to leave this beneficiary.

Please list the Name (first and last) of the Remainder Beneficiary 2:

Please enter the email of the Remainder Beneficiary 2:

Please enter the Address of the Remainder Beneficiary 2 (street, city, state, and zip)

Please enter the percentage (%) amount your would like to leave this beneficiary.

Date Submitted

Reason for Request*

Email Address

Advisory Co-Trustee Email

Address

City

State

Zip Code

Phone Number

Phone

New Bank Account Information

Account Owner Name*

Bank Name*

Bank Address*

Bank City*

Bank State *

Bank Zip Code*

Bank Routing Number*

Bank Account Number*

File Upload*

Drag and drop files here or

Signature

Acknowledgments*

By signing below the signatory certifies the following:

I am authorized to make disbursement requests on behalf of the Beneficiary.
I agree to only request disbursement for the sole benefit of the Beneficiary.
I agree pay back to the trust any expenses found to be duplicates, not for the sole benefit of the Beneficiary, or incurred after the death of the Beneficiary, or face legal liability for the the amount.
I agree to follow SSI/Medicaid rules for reporting changes to the Beneficiary’s financial situation within 10 working days (SSI/Medicaid recipients only).
I agree to notify GCT of BDI of the death of Beneficiary within 10 working days of the date of death.
I understand that GCT of BDI is a Mandated Reporter and if there is any suspected abuse, neglect, or exploitation that GCT of BDI is obligated to make a report to the appropriate state or local entity.

By checking below, I do hereby acknowledge the above

information is true and correct.

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.

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