HomeOnline Application

Online Application

Representative Payee Application

Thank you for your interest in our organization. Origin SC’s Representative Payee Program is dedicated to providing the best possible service to our clients. Below is the online application it is imperative that you fill this out with as much detail as possible. This form may not be the only form we need so please make sure you are providing good contact information. We will be contacting you to let you know we have received the application and gather any more needed information.

Part I Referring Agency

1.1 Referring agency name

1.2 Referring agency address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

1.3 Agency contact name(Required)

First Last

1.4 Agency contact phone

ext

1.5 Agency contact email

Part II Client information

2.1 Client name(Required)

First Last

2.2 Client Date of Birth(Required)

2.3 Clients Social Security Number(Required)

2.4.1 Which best describes client’s current living situation(Required)

2.4.2 Please provide address or additional information if no address(Required)

2.5 Current Rent Amount

2.6 Number of people in home

2.7 How long has client lived at address

Please enter a number from 1 to 100.

2.8 Name and relationship of all persons living with client

2.9 Former Address (if known)

2.10.Client Email

2.11 Client phone number

2.12 Client marital status

2.13 Client race

American Indian or Alaskan Native.

Asian / Pacific Islander.

Black or African American.

Hispanic

White / Caucasian.

other/ do not wish to answer

2.14 Client's city and state of birth(Required)

2.15 Client's mothers maiden name(Required)

2.16 Emergency contact

First Last

2.17 Relationship to client

2.18 Emergency contact phone number

2.19 Emergency contact address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

2.20 Does the client receive food stamps?

2.21 If yes how much

2.22 Medicare Number

2.23 Medicaid number

Income

2.24 Income Source 1(Required)

Choose one

Amount

Income Source 2

Amount

Income Source 3

Amount

Part III Reason for Service

3.1 Please explain why the client is not able to manage his/her own finances(Required)

3.2 Please list client disabilities, if any(Required)

3.3 Are there any family members or friends willing and able to serve as payee?(Required)

3.4 Does client have a court-appointed legal guardian? If yes, please provide name, address, and phone number(Required)

3.5 Has client previously had a representative payee?(Required)

* If NO, please have physician fill out SSA form 787 Linked Below *

SSA 787" target="_blank" rel="external">SSA 787

Part IV Please provide as many of the following documents as possible

4.1 State ID/ Drivers License

Drop files here or

Max. file size: 25 MB, Max. files: 2.

4.2 Medicare/Medicade cards

Drop files here or

Max. file size: 25 MB, Max. files: 2.

4.3 If possible please provide 2 of the following document types: Social Security award letter, Veterans Affairs award letter, Lease agreement, Current pay stub, State-issued birth certificate, Marriage license, School ID with photo, Work ID with photo,

Drop files here or

Max. file size: 25 MB, Max. files: 4.

Part V Forms For Client Signiture

We have some documents that we ask all new clients to fill out. These documents help us to fully server the clients needs. We offer 3 ways to receive these documents, please choice the way in which it is easiest for the client to fill out the forms.

Please select the way in which the client would like to receive the documents(Required)

Please provide the address or email address you wish for the documents to be sent to(Required)

Click here

Representative Payee Application

Part I Referring Agency

Part II Client information

Part III Reason for Service

*** If NO, please have physician fill out SSA form 787 Linked Below ***

Part IV Please provide as many of the following documents as possible

Part V Forms For Client Signiture

* If NO, please have physician fill out SSA form 787 Linked Below *