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AGED Pooled Trust
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Phone: 407.682.4111 Fax: 407.682.5511 Cell: 407.467.5832
 
 

 

 

Complete the form below to find out if you, or someone you know, qualify for the AGED Pooled Medicaid Trust. With this information we can analyze your situation and assist you with the process.


First Name : Last Name :

 
Email : Phone :

City :   State : Zip Code :


Are you disabled? :
Do you receive over $702.00 from Social Security or any other source? :

Do you have assets over $2,000 / individual or $3,000/couple? :

** This question refers to cash and investments - your home, car, and burial plot(s) do not count as assets for this evaluation. **

 
Where do you live? :

 
Do you have Medicare? :

 
Description of your situation :