FINANCIAL AUTHORIZATION	Date
Client	Meeting Date with Client
Staff	Meeting Date with WSC
Months Covered	Qtr 3/AR
Intake with new Client?	Yes	No	Date of Intake, if Yes.
When you start the program and Quarterly, staff will discuss your finances and your financial options with you, including what assistance will be provided to you, strategies to help you become more independent in managing your finances, options for managing your money, and options for a Social Security Representative Payee. You may change your designation at any time and you may look at your financial information whenever you choose.
FINANCIAL MANAGEMENT Check the appropriate box indicating your preference for managing your finances.
I can manage my own money

I agree that I will manage my own finances.
I can manage my own money and I would like help writing checks to pay bills and to reconcile my bank account(s)

I agree that I will manage my own finances and I would like help reconciling my bank account(s) and writing checks to pay bills. I have requested that specific staff of the provider assist me with this.

The staff I would like to help me is/are:

Another person (a friend, family member, guardian, other) of my choosing can manage my money for me

I agree that a friend, family member, or other person of my choosing will manage my finances.

Name of other person/relationship:

A financial institution of my choosing can manage my money for me

I agree that a financial institution of my choosing will manage my finances.

Name of financial institution:

SOCIAL SECURITY REPRESENTATIVE PAYEE Check the appropriate box indicating your preference regarding a Social Security Representative Payee.
Provider as Representative Payee

I agree that the provider is named as my representative payee to ensure my financial needs are met.

Name of provider:

Financial Company as Representative Payee

I agree that a financial company is named as my representative payee to ensure my financial needs are met.

Name of financial company:

Another person (friend, family member, other) as Representative Payee

I agree that a member of my family is named as my representative payee to ensure my financial needs are met.

Name of other person/relationship:

I am interested in exploring how to become my own representative payee.
Myself as Representative Payee

I agree that I will act as my own representative payee to ensure my financial needs are met.
Staff Holds Money/Checkbook for Me

I have requested that specific staff of the provider hold money and/or my checkbook for my expenses to ensure my needs are met. I also understand that I can change my mind at anytime.

The staff I would like to hold my money and/or checkbook is/are:

ADDITIONAL INFORMATION

Go over the information with the individual on Intake and Quarterly thereafter. Update this form Annually and provide a copy to the WSC. Provide a copy to the client and/or guardian, if requested.
Individual	Signature	Date
Client
Guardian
Staff
WSC