Client Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What is the source of your income? Check all that apply: *

SS

SSI

SSDI

DAC

Food Benefits

Qualified Government Pension

Do you work? *

Yes

No

Any other additional income source? *

Yes

No

Do you currently have a payee? *

Yes

No

Are you your own guardian? *

Yes

No

Do you live alone? *

Yes

No

Case Worker Phone:

(###)

###

####

Nature of disability: *

DDA

MH

Other

Terms *

I agree to submit a copy of my residential lease or housing agreement to The Arc of Tri-Cities, as well as a copy of all of my monthly bills-prior to the service beginning. I understand that if I am accepted into the Rep Payee Service and The Arc of Tri-Cities, I will comply with all requirements as outlined in this paperwork, as well as the accompanying Financial Management Contract and Code of Conduct Agreement. I understand that my failure to follow these requirements may result in my being terminated from this service. I understand I am responsible for a monthly fee for this service not to exceed $41.00, paid to The Arc of Tri-Cities. By checking the box below and submitting this form, I acknowledge that I have read this information, as well as the Financial Management Contract and the Code of Conduct Agreement and agree to follow everything in those documents.

I agree