Guide for Organizational Representative Payees

CONTRACT

I have discussed my needs with [Name of Organization Staffer]. I agree to have [Name of Organization] serve as my representative payee for Social Security, and/or SSI payments.

 I will:

Be clean and sober when I come to conduct business,

Treat staff with courtesy and respect,

Come to conduct business only on [days and hours organization has set up],

Receive $[amount] for spending money every [length of time] as agreed,

Sign a receipt when I receive my spending money.

In the event of a financial emergency: [Organization’s Provision].

I understand that if I fail to comply with these rules, [Organization] may refuse to continue to serve as my representative payee.

In the event of a financial emergency: [Organization’s Provision].

I understand that if I fail to comply with these rules, [Organization] may refuse to continue to serve as my representative payee.

 [Organization] will:

Treat me with courtesy and respect;

Be available on [days and hours organization has set up] to meet with me;

Use funds received on my behalf to meet my current needs for food and housing;

Report to SSA any events that may affect my eligibility for payments or payment amount;

Account to SSA on how my money has been spent or saved;

Save any unspent funds, if any, in a way that clearly shows the funds belong to me; and

Return to SSA any funds saved for me (in the event of a change in payee) or that were sent for my benefit but to which I am not entitled.

-------------------------------------- ----------------------------------------

NOTE: This contract is not an agreement to collect fees for payee services