Funds and Property Authorization
Person name:
Program name:
I authorize the program to assist me in safekeeping of the fo*lowing funds*and property:
(*heck Yes or No and describe any limitations on the amounts the program is authorized to handle)
Yes
No
Limitation on amounts
**sh
Checking Account, including knowledge
of
or access to my account number(s) or my
Personal Identification Number (PIN).
Savings Account, including knowledge of or
access to my account number(s) or my
Personal Identification Number (PIN).
Wages/Paycheck
Property
Retirement, Survivors, and Disability
Insurance (RSDI) as "representative payee"
Supplemental Security Income (551) as
"representative payee"
Minnesota Supplemental Aid (MSA)
Supplemental Nutrition Assistance Program
(SNAP) as "additional adult"
Other (specify)
Program requirements: Whenever this program assists m* with the safekeeping of my funds or other property, the program
must ensure:
1. That I retain t*e use and availability of my personal funds or property unless restrictions are justified and documented.
2. Separation of my funds from funds of other persons served by the program and from funds of the license holder, *he
program, or program staff.
3. That it immediately documents the receipt and disbursement of my funds or other property at the time of receipt or
disbursement* including my signature or the signature of my legal representative*or *ayee.
4. That *t returns to me upon my request, my funds *nd property in the program's possession and according to any justified
and documented restrictions, as soon as possible, but no later than three working days after the date of my request.
Program and staff r*strictions: I have been informed and understand that this program an* the staff must not:
1. Borrow money from me;
2. Purchase personal items from me;
3. Sell merchandise or personal services to me;
4. Require me to purchase items for which the program is eligible for reimbursement; or
5. Use my funds to purchase items for which the program is already receiving public or private payments.
Data privacy and access to financial records: The program must protect the privacy of my financial r*cords. All financial
records kept by the program are available to me, my legal representative, if any, and my case manager at any time.
Itemized financial statements: The program must complete itemized financial statements when it is responsible for safekeeping
of my funds and property. The financial statements will itemi*e receipt (money or property received) and disbursement (money
spent *r prope**y *ispose*). These i*emi*ed*financial statements wil* be *rov*de* to*me, my*le*** represent**ive, and cas* manag*r
a*c********o **r*******enc*.*T*e*p*ef*re***s **r******v****it*m**e*****anc*a* **at**e*ts**r*:
Place a check mark in appropriate box:
Other (Describe)
Semi-Annually
Quarterly
Annually
Monthly
Person/Legal representative
Case Manager
This au*horization expires annually and must be renewed. I*may revok* or revise this au*horization at any time by
making a verbal or wri*ten re*uest.
Name
Signature
Title
Date
Person
Legal
Representative
Case Manager