Intake Forms

New Client Intake Application (Manual Download)

Email
Name
Date
Current Address
Apt/Bldg #
City
State
Zip code
SSN
DOB
City of Birth
Mother's Name
Mother -Place of Birth
Father's Name
Father-Place of Birth
Cell Phone
Martial Status
Emergency Contact
Phone
Relation
Sources of Income: Monthly
SSA $
SSI $
Snap Benefits $
Other Source of Income: $
Total Income $
Do you own any securities? (Stocks, Bonds, etc.) Yes No
If yes, please list securities:
1
Value
2
Value
3
Value
4
Value
5
Value
Bank
Checking Acct
Amount
Bank
Saving Acct
Amount
Current Rep Payee
Phone:
Address
City:
State
Zip:
Emergency Contact
Social Worker:
Phone:
Email:
Who lives with you?
1
Age
Relation
Contribution
2
Age
Relation
Contribution
3
Age
Relation
Contribution
4
Age
Relation
Contribution
5
Age
Relation
Contribution
Personal Vehicle Make:
Model:
Year:
Tag Number
Operational?
Please list any other information that may be helpful below:
Monthly bills
Who do you pay?
(Name & address)
Account Number &
Phone Number
Amount Payment
Due Date
Advance Notification of Representative Payment
Name of Wage Earner, Self-Employed Person or
SSI Claimant
Social Security Number
Name of Beneficiary (if other than above)
Relationship to Wage
Name of Wage Earner, Self-Employed Person or Social Security Number
I understand and agree with the following.
Need for Representative Payee
The Social Security Administration (SSA) has decided that | need someone to manage my benefits. Because of this, SSA will send my benefits to a representative payee. Itis the duty of the representative payee to use my benefits for my best interests.
Choice of Representative Payee
SSA has selected K & L Representative Payee Services, INC to be my representative payee,
My Right to Appeal
I understand that | have the right to appeal SSA's decision. I can appeal the cholce of who will be the representative payee. In most cases, | can also appeal the decision that I need apayee. If I appeal, I will have the right to review the evidence in file and submit new evidence, I understand that I can have a friend, lawyer or someone else to help me.

I understand that I must file an appeal within 60 days. If file after the 60 day pericd, I must have a goad reason for not having filed this appeal on time, I have to ask for the appeal In writing. I will contact an SSA office if { wish to appeal.
Signature
Date
Witnesses are required only if this statement has been signed by mark (X) above, lf signed by mark (X), two witnesses fo the signing who know the person making the statement must sign below, giving their full addresses,
1. Signature of Witness
2. Signature of Witness
Address (Number and Slreat, City, State and ZIP Cade)
Address (Number and Sireat, City, State and ZIP Code)
Greetings!
We have great news! K & L now has access to Visa debit cards for all of our clients. We have listed the benefits and disadvantages of having one of these Visa debit cards to receive your allowances.
The benefits of using the True Link Visa debit card:
1, You get your money quicker! You no longer have to wait days to receive your check in the mail. Your funds will be available on your card, on the date SSA has designated for you to receive benefits.
2. Its safer than receiving cash. If you lose you cash - It's gone, Ifyou lose a card, it can be replaced and you don't lose your money.
3. You no longer have to come pick up cash or checks, so you save money on transportation.
4. You can carry a Visa card debit card in your purse or wallet and use it anywhere Visa is accepted - just like everyone else!
5. You can check your card balance by calling or texting, 24 hours a day, 7 days a week be calling the number on the back of the card.
The disadvantages of using the True Link Visa debit card:
There is a $4.00 monthly fee. You will still save with this card as it's free to withdraw your funds from any ATM located inside any Walgreens or CVS.
This is really nota disadvantage as you will save what you would have paid in ATM fees. This is a free withdrawal as long as you use the ATM inside any Walgreens or CVS.
Yes, I want the True Link debit card!
I (insert name) Chose to use the True Link Debit card for my funds distribution, instead of receiving checks or cash. | understand that | can get cash by using an ATM with no fees, as long as | am in the AllPoint network. ( See attached locations near you),
I agree to pay the $4.00 monthly fee. I also have received a copy of the fee schedule and agree to any additional fee's shown on the attached fee schedule.
Name
Signature
Date
I attest that all information provided is correct and current and I understand that it is my responsibility to provide any changes to any of the given information to K & L Representative Payee Services, Inc. as soon as I am aware of the change or changes.
I understand there is a $44 fee for service due to K & L Representative Payee Services, Inc. each month and that fee will be deducted from my monthly benefit payment. I also acknowledge that if I change my mind after this signed agreement has been turned in to the Social Security Administration and K & L becomes my payee of record that the fee will still be due to K & L Representative Payee Services, Inc., and will be deducted from my benefit payment for that month.
I hereby give K & L Representative Payee Services, Inc. express permission to discuss my information for directly related payee purposes with Social Security Administration Representatives, my case worker, social worker, therapist, landlord and any other party necessary for the management of my finances, housing and care.
I also give K & L Representative Payee Services, Inc. permission to discuss appointments made and attended/unattended with my medical providers so I may receive assistance with transportation services to and from any medical appointments.
Client Name
Client Signature
Mail Delivery & Shipping
Our regular method of delivery is via the United States Postal Service.
If for some reason you are unable to wait for regular mail delivery and prefer faster shipping, we offer two alternatives at your expense.
FedEx - Two day or next day delivery at a very discounted rate, usually under $10.00
Blue Sky – Same day delivery, usually under $15.00
Ride Share Services
In the event a ride is needed, and you are unable to take the bus, we can arrange a ride through UBER at your expense.
Signature
Date
Instacart Grocery Delivery
In the event groceries are needed and you are unable to get to the grocery store, we offer grocery delivery at your expense through Instacart. Instacart has several stores to choose from in the Memphis area. We will bill the charges against your available funds on your account.
If you don’t have funds available, we are unable to make any purchases on your behalf.
Amazon Delivery
In the event items need to be purchased over $200, we will order those items through Amazon and have them delivered to your door at your expense. This way we have a receipt, and you have your desired items. The items will be charged against your available account balance. In the event you don’t have any funds available, we are unable to make any purchases.
Signature
Date