FINANCIAL AUTHORIZATION

_____________________________________________________

(Name of Individual)

Check the appropriate box indicating your preference regarding your finances. Staff will go over your finances and this form with you every quarter.

Provider as Representative Payee

I agree that the provider is named as my representative payee to ensure my financial needs are met. I also understand that I can change my mind at anytime.

Financial Company as Representative Payee

I agree that a financial company is named as my representative payee to ensure my financial needs are met. I also understand that I can change my mind at anytime.

Name of financial company: ___________________________________________________

Family Member as Representative Payee

I agree that a member of my family is named as my representative payee to ensure my financial needs are met. I also understand that I can change my mind at anytime.

Name of family member: _____________________________________________________

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. I also understand that I can change my mind at anytime.

Other (specify)

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:

___________________________________________________________________________

Go over the information with the individual on Intake, obtain signatures and submit to the Program Administrator. For Annual and Quarterly Reviews, use this information for reference only and have the client sign the Topics form as proof the client received this information. Provide a copy if the client wants one.
Individual	Signature	Date
Individual
Guardian/Representative
Staff