PEOPLE FIRST REPRESENTATIVE PAYEE PROGRAM
PFPS, Inc.
5962 Zebulon Road
Macon, GA 31210
Tele: 478-464-5993 Fax: 478-4645992
www.peoplefirstpayee.com peoplefirstpayee@yahoo.com
PART I SERVICE INTENTIONS
1. Give brief explanation as to why the resources of People First Payee Service, Inc. are needed?
2. What is client’s disability?
3. Are there family members or friends available to provide this type of service?
4. Does the client have a court-appointed legal guardian? If yes, please provide name, address, and phone number.
5. Have client previously had a Representative Payee?
If No, please have a physician form completed.
Print Name
Signature________________________________________________________
Representative Signature____________________________________________
Date____________________________________________________________
.
Part II CLIENT INFORMATION
Name______________________________________________________________
Date of Birth_________________________________________________________
Social Security Number________________________________________________
Mother’s Maiden Name________________________________________________
City and State of Client’s Birth___________________________________________
Address____________________________________________________________
Telephone__________________________________________________________
Race______________Marital status_______________# of people in home_________
Name and relationship of persons living with claimant_________________________
__________________________________________________________________
Referring Agency Name_______________________________________________
Agency Address_____________________________________________________
Case Manager or Social Worker_________________________________________
Telephone#___________________ext.______Email:________________________
Next of Kin/Emergency Contact_________________________________________
Address____________________________________________________________
Telephone#_________________________________________________________
Relationship_________________________________________________________
Does the client receive food stamps?______________Amount__________________
Medicaid/Medicare Number_____________________________________________
