GSI Money Management Program – Client Referral Form

The GSI Money Management Program is an alternative to guardianship that provides Bill Payer or Representative Payee services for adults who are agreeable.

Bill Payer service provides one-on-one client assistance for clients who are capable of directing others in the management of their finances. GSI Money Management assessment may determine the Representative Payee service is more appropriate.

Representative Payee service is based on medical evidence, that clients are not capable of managing or directing the management of benefits in their own best interest. 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. Primarily this referral is for SSA beneficiaries (SS, SSDI, SSI). A physician’s statement (SSA-787) stating the client is not capable of managing or directing the management of benefits is required to send to the SSA; unless the client needs a successor representative payee.

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

** Eligibility Monthly Income Limit: Single - $4,020 Couple - $5,415 Maximum Liquid Assets: $35,000.00

Gender*
Client Address
Primary Language*
Client Lives With*
  • Please check at least one option
Income Source*
  • Please check at least one option
Referring Agency
Is Client Agreeable to the Program?*

Client Status Questions

Why is the Client Being Referred for Services*
  • Please check at least one option
How is the Client Paying Bills Now?*
  • Please check at least one option