N.J. Admin. Code § Tit. 8, ch. 133, app E1
Current through Register Vol. 56, No. 11, June 3, 2024
| APPENDIX E1 | |
| REPRESENTATIVE 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 | |
| As payee or potential representative payee for an Interim Assistance recipient, I understand that the recipient will have his or her community maintenance paid in full or part by the Division of Mental Health Services until a determination of the SSI claim is made. The Division will also supplement the personal needs expenses, when necessary. | |
| I understand that while the client is an Interim Assistance recipient, if I receive any client income up to the normal monthly room and board rate, I must forward it to ______________________. | |
| (Housing Provider) | |
| 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 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 the client. | |
| In the event that a representative payee selected by the client fails to abide by the terms of this agreement, the client or Division will take the necessary steps to have a new representative payee appointed. | |
| I, ___________________________, agree to the terms stated above. | |
| Witness: ___________________________________ | Signature: ____________________ |
| Address: ____________________ | |
| Date: ________________________ | ____________________ |
| ____________________ | |
| Sample Form | |
| Distribution: | |
| Business Manager (original) | |
| Client | |
| Representative Payee | |
| Financial Coordinator | |
| (Revised 11/05) | |
N.J. Admin. Code Tit. 8, ch. 133, app E1