Revised 05/21/2008

The GSI Money Management Program provide two types of daily money management assistance:

___ In the Bill Payer Program, the client maintains control over all decisions about his or her funds. He or she only needs help

keeping affairs organized and/or writing checks. The client always signs the check. The client makes good financial decisions.

___ In the Representative Payee Program, the client cannot handle funds and make financial decisions; the agency is appointed to serve as the client’s payee and manages federal benefits on behalf of the client. GSI can only be appointed to be Representative Payee for benefits from federal agencies such as: Social Security Administration, Department of Veteran Affairs, Railroad Retirement Board, or Office of Personnel Management. If the client has a source of non-federal income, such as a private pension, only Bill Payer services are available for that portion of the client’s income.

All information disclosed on this referral is confidential. Client and Referral Source contact information is required.

** Eligibility Monthly Income Limit 2008: Single - $2,000 Couple - $2,900 Maximum Liquid Assets: $35,000.00

Client Information

Name____________________________________ Date of Birth ____/____/____ Gender: □ Male □ Female

Apt Name ___________________________ Social Security Number ______-_____-_______

Address ___________________________ Phone (___) ______________

___________________________ TX ID Number __________________________________

Client Lives with: □ Alone □ Family □ Non-family Income Source: □ SSA □ SSI □ VA □ RRB □ OPM

□ Spouse ___# of People in Household Monthly Income $________ □ Other____________

Marital Status: □ Single □ Married □ Widowed Ethnicity______________________________

□ Divorced □ Separated Primary Language____________________________

Referral Source

Name __________________________________ Phone (____)___________

Agency _________________________________ E-mail ____________________________________

Address ________________________________ Relationship to client_________________________

________________________________ Is client agreeable to the program? □Yes □ No □ Don't Know

Emergency Contact: Name ______________________________________

Address ___________________________ __________________________________________

Phone (____) _____________ Relationship to client _______________________________

Physician ________________________________ Address ________________________________________

Phone (____) _______________________

_____________________________________________________________________________________________

Client Status Questions___________________________________________________________________________

Why is client being referred for services? Check all that apply.

□ Physical disability affecting bill paying □ Threat of eviction □ Memory loss or confusion

□ Mental disability affecting bill paying □ Bills not paid □ Financial Exploitation

□ Needs assistance reading & writing □ Bouncing checks □ Loss of prior bill payer or needs new payee

□ Insufficient food/money at month's end □ Paperwork piling up □ Worrisome debt estimated at $__________

Other Comments or Observations____________________________________________________________________

______________________________________________________________________________________________

How is the client paying bills now?

□ Alone □ Help from family □ Help from friend/neighbor □ Social Service/Program

Date of Referral

Assigned GSI CM:

Complete only if client declines services in person. Otherwise

cross through and complete intake information.

Notes:_______________

____________________

Call Log

Date_____Staff_____

Appt Date_________

Client Decline □ Date_______________

My signature below indicates that I DO NOT want services from GSI

________________________________________________

Client Signature (only in-person intake)