Follow the steps to successfully complete the Odm 10193 Form online.

1. Press the ‘Get Form’ button to obtain the Odm 10193 Form and open it in your preferred editor.
2. Begin by filling in the individual information section. Enter the individual's name in the format of Last, First, MI. Provide the date of birth in mm/dd/yyyy format, the 12-digit Medicaid ID number, and the case number. Then, complete the street address, including any apartment or unit number, city, and zip code.
3. Proceed to the trust information section. Input the name of the trustee (Last, First, MI), the county, and the date the trust was established in mm/dd/yyyy format. Fill in the name of the location where the trust account was established, followed by the street address, city, state, and zip code associated with this location.
4. In the account information section, complete the account name, account number, the name of the account contact, and their phone number. Then, identify the sources of income applicable by selecting all that apply from the provided options (e.g., Social Security, Company Retirement, etc.). For each source selected, enter the corresponding amount and company name if applicable.
5. Indicate the amount to be deposited into the trust along with the effective date of the deposit in mm/dd/yyyy format. Enter the monthly account maintenance fee and ensure you have the trustee's signature along with the date in mm/dd/yyyy format.
6. Review all the information entered in the form for accuracy. Once all sections are completed, you can save your changes, download, print, or share the completed Odm 10193 Form as needed.

Complete your Odm 10193 Form online today and ensure all your details are accurately submitted.