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                 WEST VIRGINIA CHILDREN WITH AUTISM TRUST BOARD
                                           CHECKLIST FOR APPLICANTS

General Information
West Virginia Code §§44-16-1 et seq. establishes the West Virginia Children with Autism Trust Board (Board) to
qualify trust accounts created to provide support for a child with autism.   When a trust is qualified under this
statute the parent or guardian establishing the trust becomes eligible for certain tax benefits.   To qualify, the
person designated as the beneficiary of the trust must meet certain eligibility requirements.   If the Board determines
that the beneficiary is eligible, we will perform the second level of eligibility review to determine whether the
trust itself meets the statutory standards.   If both eligibility standards are met – eligibility of the beneficiary and
eligibility of the trust – the Board will issue a ruling that the eligibility requirements are met, allowing the parent
or guardian eligibility to receive the tax benefits.

It is important to read the statute and observe its definitions in attempting to qualify a trust for these purposes.

Eligibility of the Individual
Applicable Definitions
“ ‘Autism’ means a complex developmental disability and spectrum disorder, whose diagnosis must be clinically
confirmed by qualified physicians and psychiatrists after extensive examination and testing, defined by a certain
set of behaviors and symptoms which affects a person’s ability to communicate and interact with others.”  West
Virginia Code §44-16-1 (a)

“ ‘Child with autism’ means a child, under the age of eighteen, who has been clinically diagnosed as having
autism to a degree to which it results in a moderate or severe impairment in two or more areas of daily living, as
the terms ‘moderate impairment’, ‘severe impairment’ and ‘daily living’ are defined under Title II or Title XVI of
the Social Security Disability Act, or a child who has been clinically diagnosed with autism and has been determined
to be disabled under either Title II or title XVI of the Social Security Disability Act for any reason.”   West Virginia
Code §44-16-1 (c)

1. Was the beneficiary of the trust a person under the age of eighteen years at the time that the trust was
created?   If the answer is yes, please provide a certified copy of the child’s birth certificate.

2. Has the beneficiary of the trust been diagnosed with autism                               ?  If the answer is yes, please provide a
statement from a physician to confirm the diagnosis.  Note:  The term “physician” includes psychiatrists,
osteopathic physicians, and medical doctors.

3. Has the beneficiary of the trust qualified for Social Security Disability benefits or SSI as a disabled
individual?  If the answer is yes, please provide documentation from the Social Security Administration.   If
the answer is no, please proceed to Question 4.

4. Has the beneficiary of the trust produced evidence that they have a condition (autism) or multiple
conditions (one of which is autism) that would meet the Social Security Administration’s definition of
moderate or severe impairment on daily living activities?                                    If the beneficiary of the trust has not qualified
for Social Security Disability benefits or SSI as a disabled individual, the person seeking to qualify the trust
must present clinical evidence that would allow the Board to conclude that the beneficiary’s condition
meets the standards established by the Social Security Administration (SSA) for a moderate or severe
impairment in two or more areas of daily living.

                                                                      Page 1 of 4

a. SSA defines “autistic disorder” as being “characterized by qualitative deficits in the development of
reciprocal social interaction, in the development of verbal and nonverbal communication skills, and in
imaginative activity.  Often, there is a markedly restricted repertoire of activities and interests, which
frequently are stereotyped and repetitive.”

b. SSA regulations state that the required level of severity for an autistic disorder in a child is met when
there are medically documented findings of “qualitative deficits in the development of reciprocal social
interaction AND qualitative deficits in verbal and nonverbal communication and in imaginative activity AND
markedly restricted repertoire of activities and interests.   Additionally, there are other age group-specific
requirements that must be met.

1. For older infants and toddlers (age 1 to attainment of age 3) the autistic condition must result in at
least one of the following:
(a)  Gross or fine motor development at a level generally acquired by children no more than one-
half the child’s chronological age, documented by an appropriate standardized test or other medical
findings, OR
(b)  Cognitive/communicative function at a level generally acquired by children no more than one-
half the child’s chronological age, documented by an appropriate standardized test or other medical
findings of equivalent cognitive/communicative abnormality, such as the inability to use simple
verbal or nonverbal behavioral to communicate basic needs or concepts OR
(c)  Social function at a level generally acquired by children no more than one-half the child’s
chronological age, documented by an appropriate standardized test or other medical findings of
an equivalent abnormality of social functioning, exemplified by serious inability to achieve age-
appropriate autonomy as manifested by excessive clinging or extreme separation anxiety OR
(d)  Attainment of development or function generally acquired by children no more than two-thirds
of the child’s chronological age in two or more areas covered by (a), (b), or (c), as measured by an
appropriate standardized test or other appropriate medical findings.
2. For children from age 3 to attainment of age 18 years the autistic condition must results in at least
two of the following conditions:
(a)  Marked impairment in age-appropriate cognitive communicative function, documented by
medical findings (including consideration of historical and other information from parents or other
individuals who have knowledge of the child, when such information is needed and available) and
including, if necessary, the results of appropriate standardized psychological tests, or for children
under age 6, by appropriate tests of language and communication  OR
(b)  Marked impairment in age-appropriate social functioning, documented by history and medical
findings (including consideration of information from parents or other individuals who have
knowledge of the child, when such information is needed and available) and including, if necessary,
the results of appropriate standardized tests OR
(c)  Marked impairment in age-appropriate personal functioning, documented by history and medical
findings (including consideration of information from parents or other individuals who have
knowledge of the child, when such information is needed and available) and including, if necessary,
appropriate standardized tests OR
(d)  Marked difficulties in maintain concentration, persistence, or pace.

c. It is important to note that the criteria listed above apply to those individuals whose disability is caused
     by the effects of autism alone.   Children who have multiple medical or psychological conditions, one of
     which is autism, may also qualify under criteria specific to their condition or conditions.   The person
     seeking to establish their qualification must provide medical documentation that would enable the Board
     to conclude that the child meets the appropriate SSA criteria for their specific condition or conditions.
     Information on SSA disability criteria can be found at www.ssa.gov.

                                           Page 2 of 4

Eligibility of the Trust
Applicable Definitions
“ ‘Qualified trust for a child with autism’ means a trust account for a child with autism that (1) Is established at
a national bank, a state bank of a state of the United States or a trust company that at all times is no less than
adequately capitalized as determined by standards adopted by United States banking regulators and that is
either regulated by state banking laws of a state of the United States or is a member of the Federal Reserve
System; and (2) has been approved by the West Virginia Children with Autism Trust Board in accordance with this
article.”   West Virginia Code §44-16-1 (f)

“ ‘Qualified trustee’ means any person authorized by the laws of this state or of the United States to act as a
trustee who has been approved by the board to serve as the trustee of a qualified trust for a child with autism.”
West Virginia Code §44-16-1 (g)

   1. Has a valid trust been created to benefit the individual with autism?   If the answer is yes, please
   provide a copy of the trust document.

   2. Are the allowable expenses to be paid by the trust for the benefit of the individual also allowable
   expenses under West Virginia Code §44-16-2?    This will be determined by reading the trust document in
   conjunction with the definitions of allowable expenses in the statute.

   3. Is the trust established in accordance with West Virginia Code §44-16-1 (f) at an appropriate bank or
   trust company?  Please provide evidence that the institution meets the standards provided in the statute.

   4. Does the person named as the trustee meet the criteria in West Virginia Code §44-16-1 (g)?  Please
   provide evidence that the trustee meets the standards provided in the statute.

   5. Does the trust authorize disbursements after the beneficiary reaches the age of eighteen years?  This
   should be apparent in the trust document provided.

   6. Does the trust also authorize disbursements at an earlier time if the parent or guardian who established
   the trust dies before the beneficiary of the trust reaches the age of eighteen years?  This should be
   apparent in the trust document provided.

                                           Page 3 of 4

Version 06.2014 
                  West Virginia Children With Autism Trust Board 
APPLICATION FOR APPROVAL OF QUALIFIED TRUST FOR CHILDREN WITH AUTISM 
GRANTOR 
        NAME OF    
        GRANTOR   LAST                       FIRST                                                   MIDDLE 
DATE OF BIRTH                /          /    SSN #                                                   RELATIONSHIP       

        ADDRESS   ADDRESS LINE 1 
                  ADDRESS LINE 2 
                  CITY                       STATE                                                   ZIP 
TRUSTEE 
        NAME OF    
        TRUSTEE   LAST                       FIRST                                                   MIDDLE 
DATE OF BIRTH                /          /    SSN # 

        ADDRESS   ADDRESS LINE 1 
                  ADDRESS LINE 2 
                  CITY                       STATE                                                   ZIP 
 CHILD/BENEFICIARY INFORMATION 
NAME OF CHILD 
                  LAST                       FIRST                                                   MIDDLE 
DATE OF BIRTH                /          /    SSN # 

        ADDRESS   ADDRESS LINE 1 
                  ADDRESS LINE 2 
                  CITY                       STATE                                                   ZIP 
DIAGNOSING         
PROFESSIONAL      NAME OF PSYCHOLOGIST, NEUROLOGIST, PSYCHIATRIST, OR SPECIFICALLY TRAINED PHYSICIAN DATE OF DIAGNOSIS 
DESCRIPTION OF 
        DIAGNOSIS 

TRUST INFORMATION 
BANK NAME 
ACCOUNT # 
Is the trust established at a national bank, state bank, or trust company?                                  YES         NO 
Does the trust limit eligible expenditures to education, housing, transportation, 
                                                                                                            YES         NO 
employment support, health, prevention, wellness, life necessities, assistive technology, 
and personal support services. 
If the trust is established with a trust company, is the company adequately capitalized?                    YES         NO 
REQUIRED DOCUMENTATION 
The clinical diagnosis from a licensed psychologist, neurologist, psychiatrist, or specifically 
                                                                                                                        YES 
trained physician MUST be attached. Have you included this document?    
An SSA determination or documentation showing impairment MUST be attached. Have you 
                                                                                                                        YES 
included this documentation? 
A copy of the trust instrument MUST be attached. Have you included this?                                                YES 
A copy of the child’s birth certificate                                                                                 YES 
                                        Please mail completed form to: 
                                          WV Autism Trust Board 
                                        c/o Tax Commissioner’s Office 
                                          P.O. Box 11771 
                                          Charleston, WV 25339 
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