Representative Payee Intake Form

Rep. Payee Intake Form
First
Last
Address
Address
Street #
City
State/Province
Zip/Postal
City and State
Do you live alone?
If no, complete information for household members:
Receives Social Security Benefits
Receives Social Security Benefits
Do you have a Guardian/Conservator?
If yes, enter their information below:
Do you have a current Payee?
If yes, enter their information below:
List agency name, phone, and primary worker

Employment Information

Are you employed?
If yes, enter their information below:
Do you receive paper checks?

Landlord or Mortgage Company Information

*Copy of Lease or Rental Agreement Required
Housing Status
For office use only

Vehicle Information

Do you have a vehicle?
If yes, enter the information below:

Background Information

Are you currently on Probation?

Emergency Contacts

Bills and Expenses

Electric
Gas
Phone
Cell Phone
Cable/Satellite
Internet
Auto Insurance
Life Insurance
Funeral Plan
Bus Pass
Weekly Living
Other
Other
Other
Other
Other

I am requesting that Horizons, A Family Service Alliance apply to the Social Security Administration to be my Representative Payee.

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, or that may in any way affect my benefits or relationship with Horizons. I understand that the list of my bills and debts is part of this application.

I understand that Horizons is not yet my payee, and will not be paying any of my bills, until they are approved by the Social Security Administration, and I have signed and agreed to the requirements of the Payee Contract.