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(513) 868-3210
Office Number

(888) 597-2751
Toll Free Number

Representative Payee Application

Please note: The information that you provide in this application will be used for the sole purpose of requesting enrollment in a program and/or service offered by our organization. All applications will be reviewed and used to determine eligibility for programs and/or services.

Fax: 513-868-3249

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  • Referral Information

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  • Client Information

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    Date Format: MM slash DD slash YYYY
  • Income SourceAmount ($) 

  • *Phone number given without dashes or spaces
  • Please attach copies, if applicable, of Physician Form (if no current payee) and Letter of Guardianship.

  • I authorize LifeSpan to be my representative payee. I understand they will follow Social Security, Veteran's Administration, and or Railroad Retirement Benefits guidelines for managing my money, as appropriate. I will continue to be active in making decisions concerning my money. I understand I will have access to my money as outlined in my monthly budget.
  • I understand that LifeSpan, when permitted by law, may release information about me without my informed, written consent such as in the event that I am deemed to be a threat to myself or others if mandated reporting is required or upon subpoena. I have received a copy of the Client Bill of Rights and Responsibilities. I am aware I am responsible for a monthly payee fee, as allowed by the Social Security Administration.
  • I hereby certify that I have completed the above intake form with factual information. I also hereby certify that my identity is truthful under the laws of perjury for the State of Ohio. By typing my signature and birth date below, I testify to my identity and desire to apply for Representative Payee services through LifeSpan, Inc.
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    Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.