Plan Of Pa Application For Representative Payee Services Template printable pdf download

Date of request______/_______/_____

PLAN of PA Application for Representative Payee Services

*Please note that an original signed application must be mailed to PLAN of PA in order to be placed on our waiting list.

Client Information

Name______________________________________________________________________________

Address - (

) ________________________________________________________________

No P.O. Box

_____________________________________________________________________________

Telephone (_______) _____________________________ County ___________________________

SS# ____________________________________________ DOB _________/__________/_________

Sources of Income – SSD $_______ SSI $_______ VA $_______ Payroll/Other: $________________

Married _____ Single ______

Children Yes _____ No _____

Living Situation _____________________________________________________________________

___________________________________________________________________________________

Does Client have a court appointed legal guardian?

Yes ______ No_______

Does the Client currently have a representative payee?

Yes ______ No_______

If yes, please explain why this change is being requested. ____________________________________

___________________________________________________________________________________

PLAN of PA only provides representative payee services to adults (18+) who have been diagnosed with a

mental disability (mental illness, mental retardation, brain injury, autism.) Please provide the following:

1) individual’s diagnosis 2) date of diagnosis, and 3) name of title of who made the diagnosis:

1)___________________________________________________________________________________

2)___________________________________________________________________________________

3)___________________________________________________________________________________

I am requesting that PLAN of PA serve as representative payee for my Social Security benefits. I

understand that my benefits will be deposited into a checking account and that I will not have direct

access to the funds. I also understand that there will be a fee for this service in accordance with Social

Security Administration rules and regulations. I also give permission for PLAN of PA to talk and share

relevant information with the Social Security Administration, financial institutions, mental

health/residential staff and other appropriate resources working with and on behalf of me. That

permission will remain in effect during the time that PLAN of PA is holding my funds.

Signature of Client:

__________________________________________________________________

Signature of Case Manager: ____________________________________________________________

Name of Case Manager & Agency_________________________________________________________

Phone # (_______) ___________________________ fax # (_______) ____________________________

PLAN of PA * PO Box 154 * Wayne, PA 19087

(610) 687-4036

Fax (610) 687-2716 Email:

Plan Of Pa Application For Representative Payee Services Template