Stilwell Payee Services

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About Us/
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Apply for Service

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About Us/
Community Resources/
What's a payee?/
Apply for Service/
Contact Us/

Please complete the following application for payee services. We look forward to serving you!

Name *

First Name

Last Name

Address *

Current address is required to process this application.

Date of Birth *

This is required for your application to be processed by Social Security

Phone Number *

A working phone number is required to process this application by Social Security. If you have no number, please describe the best way to reach you.

Social Security Number *

This is required for your application to be processed by Social Security.

VA File Number

Fill this out if you receive benefits from the Dept. of Veteran's Affairs and wish to have these benefits managed.

Mother's Maiden Name *

This is required for your application to be processed by Social Security. Put none if not known

Father's Name

Put "none" if not known

City/ State of Birth *

This is required for your application to be processed by Social Security.

Do you receive food stamps and if so, how much?

Have you ever had a payee before? If so, with whom? *

Why do you need a payee? *

Emergency Contact Name and Address (someone we can reach incase we can't reach you) *

Emergency Contact Phone Number *

Who do you live with?

Legal Guardian Name

Legal Guardian Address and Phone Number

Monthly Benefit Amount and Type *

What is your diagnosis? (reason for receiving benefits) *

Has a payee ever refused or terminated your services? Why?

Have you ever been convicted of a felony and if so, please describe. *

A "yes" answer does not mean denial of services.

Have you ever been charged, tried or acquitted with charges related to check or wire fraud, forgery, identity theft or any crime related to money? If so, please describe. *

A "yes" answer does not mean a denial of services. You may have to receive spending money by methods other than the traditional method of a check. If you are found to have lied about your answer to this question, we will discontinue your services.

Are you on probation or parole? If so, please provide officer's name and your case number(s).

Please list your monthly expenses. *

Additional household members

Primary Care Physician Contact Info *

Write "none" if you do not have a primary care physican.

Case Manager Contact Info *

Write "none" if there is no case manager.

Electric Provider and Account Number *

Write "None" if not required to pay.

Gas Service Provider and Account Number *

Write "None" if not required to pay.

Other Utility Provider (write none if none) *

Write "none" if not required to pay.

I understand that the following information is used to process my application for Stilwell Payee Services to become my organizational representative payee. *

A "no" answer will lead us to decline this application.

Yes

No

I understand that it is my responsibility to provide my bills to Stilwell Payee Services in a timely manner so that they may be paid. *

A "no" answer will lead us to deny this application. We must know all expenses if we are to provide the best service.

Yes

No

I understand that I am to be treated with respect by Stilwell Payee Services and it is expected that I treat staff of Stilwell Payee Services with respect. I understand that continued abusive behavior or threats will lead to the discharge of my services. *

Yes

No

I understand it is my responsibility to inform my representative payee of any life changes that may affect my benefit eligibility including but not limited to: Marriage, Divorce, Change of Residence, Birth or Death of Household Member, Change of/New Employment. I understand it is my responsibility to provide the supporting documentation of these changes to my payee. *

Yes

No

I understand that weekly spending checks are provided for my spending money, unless otherwise arranged. I understand that I am not permitted to use the account information for anything other than cashing my spending money check. Unauthorized use of account information will lead to a permanent denial of future services with Stilwell Payee Services. Unauthorized use of checking account information will be reported to Social Security as well as the local police department, if appropriate.

Spending money checks are not permitted for use to open payday loans or set up direct withdrawal from vendors. A "no" answer will lead us to deny your application.

Yes

No

I understand that it is my responsibility to sign and return spending money sheets on a monthly basis as well as receipts when requested. I understand that my spending money will be suspended if I do not provide the required signature sheets. *

Signatures for all funds dispersed is required by Social Security. A "no" answer will lead to denial of your application.

Yes

No

Other Notes

Is there anything we should know that will allow us to better serve you? Our goal is your satisfaction and financial stability.

Thank you!

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Stilwell Payee Services

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