Please fill in the information below:

Patient's Name:              

Patient's Social Security Number: 

County of Texas in which Patient resides:            

Name of Spouse:

The Trustee should be (name) (often this is the spouse, but it need not be...):
  who lives at   (city, state, zip)

If the first Trustee cannot act or dies, then the second Trustee should be (name):  

If both the first and second Trustees cannot act or die, then the third Trustee should be (name): 

Eventually, when the patient dies, there should be very little money in the Miller Trust. The state of Texas has first claim on the balance, as reimbursement for its expenses. However, if there is any money left after the state's claim (or if the state does not make a claim) then the following person or persons should receive the small amount that may still be in the trust:

Email address to which completed document should be sent:

I want Attorney Paul Premack to prepare a QIT/Miller Trust. To the best of my ability I will provide complete and accurate information to Mr. Premack, because I understand he relies on the information I provide without verification. I confirm that a QIT/Miller Trust is needed by me for Medicaid purposes, and that I understand that the QIT will operate only to bring the "patient" below the income limit for Medicaid. I acknowledge that I understand there are also asset limits before the "patient" can qualify for Medicaid, and that I have taken those limits into consideration before submitting this order.

Refund Policy: No refund is allowed.

Limits: I recognize that Mr. Premack will be providing drafting services only, and does not represent me in any other manner. If I desire services beyond drafting of the QIT/Miller Trust, I will either hire Mr. Premack separately after direct consultation with him, or will hire other counsel.

If you do not agree to these terms, click here to return to the Premack home page

Clicking "submit and purchase" will send your data to Premack and enter this selection in your "shopping cart." Remember to "check out" when you are ready to pay. When payment is confirmed, Mr. Premack will prepare and Email your completed document to you.