Secure Client Intake

New Client Intake Application

Complete each section, review your information, and submit the application securely. Fields marked with an asterisk are required.

Secure submissionYour completed application is encrypted before it is stored. Do not use public or shared computers for this form.

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Part 1 of 9Personal Information

Full legal name *

Email address *

Date of birth *

Cell telephone *

Marital status

Current address *

Apt./Building

City *

State *

ZIP code *

City of birth

Last four digits of SSN *Enter only the last four digits.

Emergency Contact

Name *

Telephone *

Relationship *

Part 2 of 9Income and Assets

Enter estimated monthly amounts. Use 0 when a source does not apply.

SSA

SSI

SNAP benefits

Other income

Describe other income

Checking bank name

Approximate checking balance

Savings bank name

Approximate savings balance

Stocks, bonds, or other securities

Part 3 of 9Current Support Contacts

Current Representative Payee

Name or organization

Telephone

Address

City

State

ZIP code

Social Worker or Case Manager

Name

Telephone

Part 4 of 9Household and Transportation

List people currently living with the client.

NameAgeRelationshipMonthly contribution

Personal Vehicle

Make

Model

Year

Operational?

Other helpful information

Part 5 of 9Monthly Bills

List regular expenses. Do not enter full account numbers; last four digits are sufficient.

Payee / expenseAccount last 4AmountDue day (1–31)

Part 6 of 9Representative Payee Acknowledgment

Need for a Representative Payee

I understand that the Social Security Administration may decide that I need someone to manage my benefits and that a representative payee must use those benefits in my best interests.

Choice and Appeal Rights

I understand that SSA selects the representative payee and that I may have the right to appeal the selection or the determination that I need a payee. I may contact Social Security for information about appeal requirements and deadlines.

I have read and understand this acknowledgment. *

Beneficiary name *

Wage earner / claimant name, if different

Part 7 of 9Allowance Card Preference

True Link Visa Debit Card

KLRPS may offer an allowance card as an alternative to checks or cash. Card availability, current fees, withdrawal options, and the complete fee schedule will be reviewed with you before enrollment.

Would you like more information about the allowance card? Yes No Unsure

Part 8 of 9Delivery and Optional Services

Standard MailRegular delivery through the United States Postal Service.Expedited ShippingAsk about available paid delivery options.Ride SupportAsk whether transportation can be arranged at the client’s expense.Grocery DeliveryAsk about grocery ordering using available client funds.Online PurchasesAsk about documented online orders using available client funds.

I understand that optional delivery, transportation, or purchasing services may involve charges paid from available client funds. *

Part 9 of 9Review, Authorization, and Signature

Review the information entered in each section before submitting.

I attest that the information provided is correct and current to the best of my knowledge. I understand that I must notify KLRPS of relevant changes. I authorize KLRPS to discuss information directly related to representative payee services with appropriate agencies, caseworkers, housing providers, and other parties necessary to manage approved services.

Service fees, responsibilities, privacy practices, card fees, and optional service charges will be confirmed in the final service agreement before activation.

Typed legal name *

Date *

By checking this box and typing my name, I consent to use this electronic signature for this application. *