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Representative Payee Intake Form

Thank you for your interest in our Representative Payee services. To be eligible for the program, you must be required by the Social Security Administration to have a representative payee. If you meet this requirement, please complete the attached intake form, provide copies of the documents required, and return at your earliest convenience. Once all information is received, a Horizons representative will contact you to begin the process.

Horizons will schedule an appointment with the SSA to apply as your representative payee once we have received the following items:

  • Completed intake form
  • Copy of identification and Social Security card
  • Guardianship letters of appointment, if applicable
  • Rental lease and/or housing authority paperwork
  • Utility bills (gas, electric, water)
  • Pharmacy bills
  • Mobile phone provider
  • Cable/Internet provider
  • Renter’s insurance

If you cannot complete this form online for any reason, please contact Horizons at 319-398-3943.

Once Horizons has been approved as your representative payee, please update your billing address for the above items to:

c/o Horizons, A Family Service Alliance
P.O. Box 2904
Cedar Rapids, IA 52406

Representative Payee Intake Form

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      Name(Required)
      Date of Birth(Required)
      Address(Required)
      I consent to receive updates via text message.(Required)
      Veteran(Required)
      Marital Status(Required)
      Highest education completed(Required)

      Benefit/Income Information

      Type of Benefit(Required)

      Are you employed?(Required)
      Do you receive any other types of income?(Required)
      Do you receive Supplemental Nutrition Assistance Program (SNAP) benefits?(Required)
      Case Manager Name
      Do you have a Legal Guardian/Conservator?(Required)
      Do you have a current Payee?(Required)
      Are you currently on probation?(Required)
      Select any of the following assets you have:
      I am authorizing Horizons, A Family Service Alliance to contact any or all of the people, businesses, or agencies listed in this application to verify or discuss any of the information contained in this application. I understand that I must provide the list of required information as part of this application. I understand that Horizons, A Family Service Alliance is not yet my payee, and will not be able to pay any of my bills or provide me funds until they are approved by the Social Security Administration to do so.
      Date

      ""

      Horizons Family Services

      819 5th St SE
      PO Box 667
      Cedar Rapids, IA 52406-0667

      Phone:
      319-398-3943
      877-653-3123

      Fax:
      319-398-3577
      877-453-2775

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