N.J. Admin. Code § Tit. 8, ch. 133, app E
Current through Register Vol. 56, No. 24, December 18, 2024
| APPENDIX E | |
| PAYEE AGREEMENT | |
| As used in this agreement, the term "Housing Provider" shall mean a congregate residence provider, a landlord, or a family member. In addition, this agreement shall apply to situations where the client lives independently. | |
| I understand that I, as an Interim Assistance recipient, will have my community maintenance paid in full or in part by the Division of Mental Health Services until a determination of my SSI claim is made. The Division will also supplement my personal needs expenses, when necessary. | |
| I also understand that income available to me or my representative payee while I am an Interim Assistance recipient, up to the normal monthly room and board rate, must be turned over to __________________________, toward | |
| (Housing Provider) | |
| payment of room and board expenditures. | |
| I therefore agree: | |
| 1. To notify the Business Manager, ____________________ Psychiatric Hospital, when income or resources from any source becomes available to me or my representative payee; and based on the Business Manager's direction, I agree to turn over all income or resources received by me (but not exceeding my monthly room and board rates) to the _______________________, until recurring SSI is available. | |
| (Housing Provider) | |
| 2. That, if there are insufficient recoverable funds available from the initial SSI retroactive check for full reimbursement of Interim Assistance funds granted, the balance owing may be recovered by the hospital business office from other sources of funds available to me. | |
| In the event that a representative payee selected by me fails to abide by the terms of this agreement, I will take the necessary steps to have a new representative payee appointed. | |
| payment of room and board expenditures. | |
| I therefore agree: | |
| Witness: ___________________________________ | Signature: ____________________ |
| Address: ____________________ | |
| ____________________ | |
| Date: _______________________ | |
| Sample Form | |
| Distribution: | |
| Business Manager (original) | |
| Client | |
| Representative Payee | |
| Financial Coordinator | |
| (Rev. 11/05) | |
N.J. Admin. Code Tit. 8, ch. 133, app E