888101 Payeeintakeform
User Manual: 888101
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People First Payee Services Intake Form
Today’s Date: _______________
Name: __________________________________ Soc.Sec.#______________________________
Mailing address: __________________________ DOB__________________________________
Phone: __________________________________ Referral Agency: _________________________
Picture ID___Yes_____No Caseworker____________________________
Mother’s Maiden Name: ________________________ Place of Birth____________________________
Guardian: ________________________________
Emergency Contact Person: _______________________________________________
Living Arrangements: ______________________________________________________
Contact Person: ____________________________ Phone #: __________________________ Method of
Monthly Contact: ________________________________________ _____________
Type of Income: _______________
Medicaid #: ____________________________Medicare #: _______________________________
Commercial Ins. ___________________________
Monthly Expenditures:
Housing: _______________
Telephone: _______________
Utilities:__________________
Transportation: __________________
Food: _________________
Clothing: __________________
Medical : ________________
Bank Routing Number___________________________________________________________
Acct #: Checking: ________________________________________
Acct # -ATM card ______ Debit_______ No card/checks_____________
Bank acct opened______________ SSA visit date________________ Est. direct dep. Date________
FILL OUT AND SEND TO:
Box 888101 GR 49588
OR
FAX TO: 616-455-2505
QUESTIONS? Phone: 616-455-2505
