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
