Representative Payee Services Application

Application Overview

Welcome to the Indiana County Community Action Program, Inc. Representative Payeeship Program Application. This application is used to request Representative Payee services through ICCAP.

Please complete all questions as accurately as possible. Applications cannot be fully processed until all required information, required documents, and required acknowledgments are received.

ICCAP manages Social Security payments, SSI, SSDI, pensions, VA benefits, Black Lung benefits, or wages by depositing them into an agency Representative Payee account with our local bank. Income is used to meet client needs first, including shelter and utilities, food, medical costs, legal obligations, clothing, and spending money.

Forms & Documents Needed

Before submitting this application, please be prepared to provide copies of the following documents:

Driver's License or State ID
Medical Insurance Cards, including Medicaid and/or Medicare.
Social Security Card
Birth Certificate, if available.
Current Rental Lease or Room and Board Agreement
Any other documents requested by ICCAP or Social Security.

Important: Applications will not be processed until required documents are received.

Application Consent *I UnderstandI understand that ICCAP cannot fully process my Representative Payeeship application until all required information, signatures, acknowledgments, and documents are received.

Social Security Forms Required for Application Process

At minimum, you must have the following forms completed and ready to upload before continuing (Click to Download):

SSA-827 — Authorization to Disclose Information to the Social Security Administration

SSA-787 — Medical Source Opinion of Patient's Capability to Manage Benefits

If these forms are missing, incomplete, unsigned, blurry, or unreadable, ICCAP will not be able to begin the Representative Payeeship application process.

Form SSA-827: Authorization Requirement

Do you have a completed and signed Form SSA-827 ready to upload? *YesNoReminder: Applications submitted without a completed SSA-827 may be delayed or unable to be processed.

A completed and signed SSA-827 is required before ICCAP can move forward with the Representative Payeeship application process.

Please complete the SSA-827 before returning to this application. If you have questions, contact ICCAP at reppayee@iccap.net.

Upload file *

No file chosen

Form SSA-787: Medical Source Opinion Requirement

The SSA-787 Medical Source Opinion is required for most Representative Payeeship requests submitted to Social Security. This form must be completed by a physician, psychiatrist, or qualified medical provider and helps support the request for Representative Payeeship services.

In limited situations, such as an urgent financial concern, inability to access a medical provider, homelessness, safety concerns, or another emergency circumstance, ICCAP may review a written letter of concern or support from a case manager, hospital, shelter, behavioral health provider, protective services worker, or other supportive agency.

This exception is not the normal process. If you do not have a completed SSA-787, please do not continue with the online application unless instructed by ICCAP staff.

Do you have a completed and signed Form SSA-787 ready to upload? *YesNoReminder: Applications submitted without a completed SSA-787 may be delayed or unable to be processed.

The SSA-787 is required for most Representative Payeeship requests. If the consumer cannot see a doctor, is experiencing an urgent financial situation, or needs emergency review, please contact ICCAP directly before continuing.

A case manager or supportive agency may be able to submit a written letter of concern or support in place of the SSA-787 only when approved by ICCAP.

Please contact the Representative Payeeship Department at reppayee@iccap.net.

Do not continue with this online application unless ICCAP staff instructs you to do so.

Upload file *

No file chosen

Please upload the completed SSA-787. The form must be completed by a physician, psychiatrist, or qualified medical provider and must include all required pages, dates, and signatures. Uploads must be clear, readable, and not blurry, cut off, or incomplete.

Applicant Information & Demographics

Full Name *Full Legal Name

Date of Birth *

Social Security Number *Please enter your full Social Security Number in the following format: ###-##-####.0 / 11

BSU Number, if applicable.If you do not have a BSU number assigned, please leave this field blank.

Primary Language *EnglishEspañolOther

Is an interpreter needed? *YesNo

Contact Information

Street Address (Line 1) *

Street Address (Line 2)

City *

State/Province *

ZIP / Postal code *

Is your mailing address the same as your current address? *YesNo

Street Address (Line 1) *

Street Address (Line 2)

City *

State/Province *

ZIP / Postal code *

Primary Phone Number *

Secondary Phone Number

Email Address *

Confirm Email Address *

Living Arrangements

Current Living Situation *

Name of Facility, Landlord, or Housing Contact *

Phone Number of Facility, Landlord, or Housing Contact *

Monthly Rent or Room and Board Amount *

Are utilities included? *YesNo

Do you have any housing concerns, landlord concerns, utility shutoff notices, eviction notices, or housing changes ICCAP should know about? *YesNo

Please list those concerns here: *

Benefit Information, SSA, & Other Income

Social Security Benefits Received *Supplemental Security Income (SSI)Social Security Disability Income (SSD/SSDI)SSA Retirement BenefitsSSP (CAO Supplement - $22.10/Mo.)Black Lung BenefitsOther

Check all that apply.

SSI Monthly Amount *

SSDI Monthly Amount *

SSA Retirement Monthly Amount *

SSP-CAP Monthly Amount *

Black Lung Benefit Monthly Amount *

Approximate Benefit Began Date *

VA Benefits Monthly Amount *

Pension Monthly Amount *

Employment Income Monthly Amount *

SNAP/Food Stamps Monthly Amount *

Other Income Monthly Amount *

Please explain any other income, expected income changes, pending benefit applications, or recent benefit changes. *If none are expected, please enter "none."

Request for Representative Payee Services

Reason for Requesting Representative Payee Services *Difficulty Managing MoneyCognitive or Mental Health ImpairmentSubstance Use ConcernsPhysical or Health Limitation(s)Court or Agency ReccomendationNo Trusted Individual AvailableHousing InstabilitySocial Security ReqirementOther

Check all that apply.

Has anyone previously served as your Representative Payee? *YesNoUnsure

Previous Representative Payee Name *

Previous Representative Payee Phone Number *

Does ICCAP have permission to contact the previous Representative Payee? *YesNo

Current Financial Obligations & Budgeting

Rent/Room and Board Monthly Amount *

Electricity Monthly Amount *

Heating/Fuel Monthly Amount *

Water/Sewerage Monthly Amount *

Trash Collection Monthly Amount *

Phone, Internet, & TV Monthly Amount *

Fines/ Legal Monthly Amount *

Insurance Premium Monthly Amount *

Child Support Monthly Amount *

Other Expense Monthly Amount *From "Other" in "Current Monthly Expenses" question above.

Rent Arrears Amount Due *

Utility Arrears Amount Due *

Medical Bills/Debts Amount Due *

Court Fines Amount Due *

Credit Card/Loans Amount Due *

Other Debt Amount Due *

Banking and Funds

Do you currently have a bank account? *YesNo

Bank Name *

Current Account Balance, if known

Does this account have a debit card? *YesNo

Do you have any bank account concerns, overdrafts, account closures, direct deposit issues, or card concerns? *YesNo

Please explain the concerns: *

Supports & Case Management

Do you currently have a case manager or caseworker? *YesNoUnsure

Primary Case Manager or Agency Name *

Case Manager Contact Person *

Case Manager Phone Number *

Case Manager Email Address *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Emergency Contact Email Address *

Will this emergency contact know how to get ahold of you at all times? *YesNo

Do you have any other agencies, family members, providers, or supports that you would like ICCAP to know about? *YesNo

Please list: *

SSA Verification & Consent

ICCAP may need to contact the Social Security Administration to verify benefit information, application status, payment information, and other information needed to process and manage Representative Payeeship services. The following information is required by the Social Security Administration for verification during communication with our agency.

I authorize Indiana County Community Action Program, Inc. to contact the Social Security Administration to verify my benefit information and apply to serve as my Representative Payee if accepted into the program. *I Agree

I authorize Indiana County Community Action Program, Inc. to receive, manage, and disburse my SSA benefits if approved as Representative Payee. *I Agree

Mother's Maiden Name *This is required for Social Security Administration verification and updates.

Father's First & Last Name *This is required for Social Security Administration verification and updates.

Place of Birth (City & State) *Your place of birth.

Release of Information

By completing this section, you authorize ICCAP to exchange information with selected agencies or individuals as necessary to provide Representative Payeeship services or additional support services.

I authorize ICCAP to exchange information with the following entities, as needed: *Social Security Administration (All Offices)All Medical ProvidersAll Behavioral Health ProvidersAll Housing Providers/LandlordsAll Utility CompaniesAll Financial InstitutionsAll County Assistance OfficesAll Other ICCAP ProgramsOther

I authorize ICCAP to exchange information with the appropriate behavioral health administrative agency or provider for the purpose of determining eligibility, completing inquiries, and maintaining participation in the Representative Payeeship Fee-for-Service billing program, if applicable. *Armstrong-Indiana Behavioral & Developmental Health Program (AIBDHP) — Indiana & Armstrong CountiesThe Family Counseling Center (FCC) — Armstrong CountyThe Community Guidance Center (CGC) — Indiana CountyI do not live in Indiana or Armstrong County.Not applicable / I do not authorize this releaseICCAP may need to contact one or more of the agencies below to determine whether the monthly Representative Payeeship Fee-for-Service amount may be covered through the applicable county behavioral health program. Please select the agency or agencies that apply based on the consumer’s county, services, or provider involvement.

This authorization is valid for one year from the date signed unless revoked in writing.

I understand that this Release of Information is valid for one year from the date of submission unless revoked in writing. *I Understand

Do you currently have any arrangements or funds set aside for burial or funeral expenses? *NoneBurial PlotInsuranceIrrevocable Burial or Funeral TrustRevocable Burial or Funeral AccountPrepaid Funeral ContractUnsureCheck all that apply. If you have no burial or funeral plans, please select "None."

Provider, Funeral Home, or Trust Name *

Estimated Value *If known.

Location, account number, or other funeral/burial details. *

Client Rights & Responsibilities

I understand that ICCAP will manage my SSA benefits in my best interest. I will receive regular updates on my finances upon request. I may request a change or termination of payeeship services. ICCAP may discontinue services if program requirements are not met.

I acknowledge & agree to the Client Rights & Responsibilities statement.

Client Certification

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I certify that the information provided is true and accurate to the best of my knowledge. I am voluntarily requesting Representative Payeeship services from ICCAP.

First Name *

Middle Initial

Last Name

Today's Date *

By checking this box, I certify that the information submitted is true and accurate and that this checkbox serves as my electronic acknowledgment.

If Client Is Unable to SignOnly fill out the following section if the applicant or consumer is unable to sign the application themselves.

Authorized Representative NameIf applicable.

Relationship to Applicant

Authorized Representative Date of Signing

I certify that I am completing this application on behalf of the applicant because the applicant is unable to complete or sign this application independently.

Budget Review and Update Schedule

The consumer acknowledges and agrees that budget reviews and updates are conducted on a quarterly basis only, unless otherwise required by law or due to an emergency circumstance as determined by ICCAP.

Budget updates will be scheduled during the following months each year: January, April, July, and October.

Requests for budget changes made outside of these aligned review periods may not be approved and may be deferred to the next scheduled quarterly review.

I understand and agree to ICCAP's quarterly budget review and update schedule.

Fee for Service Agreement

I agree to pay a fee for services provided by ICCAP's Representative Payeeship Program. The Fee-for-Service Program was explained to me in detail, and I understand that ICCAP may deduct the authorized monthly fee from my Social Security benefit when permitted by the Social Security Administration.

I agree to the Fee for Service Agreement.

First Name *

Middle Initial

Last Name

Today's Date *

Agreement Between ICCAP Representative Payeeship Department and Consumer

I give permission for ICCAP to act as my Representative Payee for government checks issued in my name.

ICCAP agrees to follow program guidelines, including depositing benefit checks into an agency Representative Payee account at a local bank, maintaining financial accountability, managing finances according to program rules, allocating monthly benefits to provide for care and well-being in the community, and helping connect the consumer with additional community resources when appropriate.

By agreeing to this section, I acknowledge and understand that ICCAP will manage and disburse benefits in accordance with Social Security Administration regulations, ICCAP program policies, and financial stability needs.

I agree to the Agreement Between ICCAP Representative Payeeship Department and Consumer.

First Name *

Middle Initial

Last Name

Today's Date *

Consent Agreement to Report Changes

I agree to promptly notify ICCAP of any changes or events that may affect eligibility, benefits, finances, housing, or service needs. This includes, but is not limited to:

Change in residence or mailing address
Admission to or discharge from a hospital or medical facility
Incarceration or release from a correctional facility
Change in household composition or roommates
Marriage, separation, or divorce
Starting or stopping employment
Change in income, including submission of all pay stubs
Opening, closing, or holding additional bank accounts
Ownership of assets such as stocks, bonds, mutual funds, or similar investments
Burial funds, funeral arrangements, or prepaid burial resources
Prior application for any form of credit or financing
Inability to attend a scheduled appointment
Beginning any new financial obligations or services such as cable, internet, phone, or similar expenses

I agree to promptly report changes to ICCAP as described above.

First Name *

Middle Initial

Last Name

Today's Date *

Program Progression, Expectations, & Termination Policy

The ICCAP Representative Payeeship Program is designed to support long-term financial stability and self-sufficiency. Participation may progress through different stages as determined by ICCAP based on the consumer's needs, skills, and compliance.

Possible progression stages may include ICCAP managing all bills and the consumer receiving an agreed expense fund allocation; the consumer managing selected bills and receiving an approved expense fund allocation; the consumer managing all funds under ICCAP supervision; or the consumer transitioning out of the program with sufficient skills to independently manage finances.

Consumers residing in a personal care facility may receive a monthly Personal Needs Allowance when applicable.

I understand and agree that ICCAP reserves the right to terminate participation for program violations or failure to comply with program expectations.

I understand and agree to the Program Progression, Expectations, & Termination Policy.

Probation & Termination of Services

Failure to comply with program expectations may result in disciplinary action, including probation or termination of services. Behaviors that may result in probation or termination include disrespectful or inappropriate treatment of the assigned Payee Specialist; disrespectful or inappropriate treatment of ICCAP staff in person or by phone; appearing at ICCAP under the influence of drugs or alcohol; providing false or misleading information; appearing at ICCAP offices without a scheduled appointment when walk-in appointments are not accepted; and inappropriate behavior in the office.

Immediate termination may occur for physical, verbal, or sexual abuse of any ICCAP staff member, threats made toward ICCAP staff, repeated violations of the appointment-only policy, or attempted misuse or unauthorized access of ICCAP Payee accounts or funds.

I understand that failure to comply with program policies may result in probation or termination of services.

First Name *

Middle Initial

Last Name

Today's Date *

Notice of Privacy Practices

This notice describes how personal information may be used and disclosed and how the applicant may access this information.

ICCAP may collect and maintain client record information, including name, address, income information, plan for future provision of services, legal documents, and service-related notes. This information helps ICCAP provide services, coordinate care, improve outcomes, and make informed decisions.

ICCAP is required to maintain the privacy of client information, provide notice of legal duties and privacy practices, follow the terms of the notice, and accommodate reasonable requests to view, review, or modify client records as allowed.

ICCAP will not use or disclose information without authorization except as described in the Notice of Privacy Practices or as otherwise required or permitted by law.

Information Rights

The applicant may request that ICCAP not use or disclose information for a particular reason related to services. ICCAP is not always required to agree to such requests. The applicant may request information by alternative means or at an alternative location. The applicant may request to view or receive a copy of information about them, may request correction of incomplete or incorrect information, may request a list of certain disclosures made by ICCAP, and may revoke authorization except to the extent action has already been taken.

I acknowledge receipt of the Notice of Privacy Practices.

First Name *

Middle Initial

Last Name

Relationship to Applicant *SelfAuthorized RepresentativeOther

Effective Date *

Document Uploads

Please upload clear copies or photos of the required documents. If you do not have a document available, you may still submit the application, but ICCAP may not be able to process the application until required documents are received.

State ID or Driver's License (Front & Back) *

Please upload clear, readable copies or photos of each requested document. All text, names, dates, numbers, and signatures must be visible and easy to read. Photos should be taken in good lighting, with the full document shown, no cut-off edges, no glare, and no blurry images. If ICCAP cannot read the document, we may ask you to resubmit it, which may delay application processing.

Social Security Card (Front Only) *

No file chosen

Please upload a clear, readable copy or photo of the requested document. All text, names, dates, numbers, and signatures must be visible and easy to read. Photos should be taken in good lighting, with the full document shown, no cut-off edges, no glare, and no blurry images. If ICCAP cannot read the document, we may ask you to resubmit it, which may delay application processing.

Current Rental Lease (or) Room & Board Agreement *

No file chosen

If living with a friend or family member, please upload a document from that friend/family member agreeing to living arrangements.

Do you have medical, dental, vision, or other insurance? *YesNo

Medical Insurance ID's (Upload All) *

Please upload clear, readable copies or photos of each requested document. All text, names, dates, numbers, and signatures must be visible and easy to read. Photos should be taken in good lighting, with the full document shown, no cut-off edges, no glare, and no blurry images. If ICCAP cannot read the document, we may ask you to resubmit it, which may delay application processing.

Do you have a copy of your birth certificate? *YesNo

Birth Certificate *

No file chosen

Please upload a clear, readable copy or photo of the requested document. All text, names, dates, numbers, and signatures must be visible and easy to read. Photos should be taken in good lighting, with the full document shown, no cut-off edges, no glare, and no blurry images. If ICCAP cannot read the document, we may ask you to resubmit it, which may delay application processing.

Do you have any additional supporting documents that you would like to upload for your application? *YesNo

Additional Supporting Documents *

Required SSA Forms Notice

Additional forms are required before ICCAP can process or submit a Representative Payee request to the Social Security Administration.

These include:

SSA-827 Authorization to Disclose Information to the Social Security Administration
SSA-787 Medical Source Opinion of Patient's Capability to Manage Benefits

The SSA-787 must be completed by a physician, medical provider, or psychiatric doctor. This form is required for all new Representative Payee requests, including transitions from one payee to another.

I understand that additional Social Security forms may be required and that the SSA-787 must be completed by a physician or psychiatric doctor when required.

Final Review & Submission

Please review all information before submitting. By submitting this application, you certify that the information provided is accurate to the best of your knowledge and that you are requesting Representative Payeeship services through Indiana County Community Action Program, Inc.

I certify that all information provided in this application is true and accurate to the best of my knowledge.

I understand that submitting this application does not guarantee acceptance into the Representative Payeeship Program and that ICCAP must review the application before services can begin.

Representative Payeeship Program Application

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