Representative Payee

							(Rev 4/27/10)
                Representative Payee Additional Disbursement Request Form
                      Please fax this form to a BFC RPP Staff: 202-265-1970

Date of Request:                                         Time of Request:

Consumer Name:                                                           SSN:

Clinical Team Member:                                                  Phone:

Request Information: (Requested disbursement date must be 2nd business day after receipt.)
Requested Disbursement Date:

Pay to:                                                             Amount:     $

For (describe expense):

Disbursement Method:           pick-up by:                                             NW        SE

                               mail to:



**All Additional Disbursement Request Forms must include signatures of both the CSA staff member and
Immediate Supervisor. Request made payable in the name of a CSA staff member in any amount, to the
consumer or to a third party in the amount of $250.00 or more must also include the signature of a Senior
Administrator or designee and must be picked up by or mailed to the Case Manager.

Comments:
Requests this month:  1st         2nd      Emergency (please describe)




Signature, Clinical Team Member ________________________________________________

Signature, Clinical Team Supervisor ______________________________________________

Signature, Senior Administrator _________________________________________________

For vendor use:
Funds available:      YES          NO

Check issued:         YES          NO      If yes: Check No. __________ Date: _________

If no, call to Clinical Manager     YES            NO

Contact note/resolution:


Representative Payee Signature:
                                                                     Date: