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Shared Living
About us
Housing
Shared Living
Transportation
Money Management
Contact
Money Management/Organizational Payee Intake Form
We are available to assist you in completing this application by calling 216.832.1565 or by Email Admin@faithfulhomes.biz
Please let us know what services Faithful Transport would provide for you.
Budget development
Banking (checking, savings, wage accounting
Utility Bill charges/payments
Bill Payment
Fund Distribution to bank account
Funds Distribution for larger purchases
Food Stamps, SNAP application/redetermination
Medicaid Applications/ Redetermination
Social Security Organizational Payeeship
Social Security/ SSI annual evaluations
STABLE Account Set-up/maintenance
Tax Referral/completion
Notary Services
Consultation Meetings to discuss services (quarterly, semi annually, annually, ISP)
Other...
Client Email
*
Client Name
*
First Name
Last Name
Client's Date of Birth
*
MM
DD
YYYY
Client's Social Security Number
*
Client Lives
Alone
In Shared Living Setting
In Congregate Setting
Other residential setting
Client's Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Should we have questions for you, what is the best time to reach YOU?
Mornings (8am-12pm)
Afternoon (12pm-5pm)
Evening (5pm-9pm)
Client's Personal Phone Number
(###)
###
####
Client's Place of Birth (City and State)
Mother's Full Name (if available on birth certificate)
First Name
Last Name
Mother's Maiden Name
Mother is (if known)
Alive
Deceased
Father's Name, if available from birth certificate)
First Name
Last Name
Father is
Alive
Deceased
Mother's Maiden Name
I/O Waiver
I/O Waiver / Lives Alone
Level One (1) Waiver
Adult Foster Care
Client's Medicaid Number
DODD/OH Residence Number
Client's Medicare Number
Client's SNAP Case Number
EBT Card Number
Client's Employer or Day Center
Employer or Day Center's Phone Number
(###)
###
####
Employer or Day Center's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer or Day Center's Contact Name
First Name
Last Name
Employer or Day Center Email Address
Client's Landlord's Name
First Name
Last Name
Landlord's Phone Number
(###)
###
####
Landlord's Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Landlord's Email Address
Client's Housemate name(s)
Additional Close Friend(s) or Support
Support Team
We are available to assist you in completing this application by calling 216.832.1565. We also have a Notary available to assist where needed.
Provider's Contact Name
(Example: Residential provider - congregate living provider/ shared living provider, HPC provider)
Provider's Contact Phone Number
(###)
###
####
Provider's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Provider's Email Address
Support Administrator's Name
*
First Name
Last Name
Support Administrator's Office Phone Number
*
(###)
###
####
Support Administrator's Cell Phone Number
(###)
###
####
Support Administrator's Street Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Support Administrator's Email Address
Guardian's Name
First Name
Last Name
Guardian's Phone Number
(###)
###
####
Guardian's Street Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Guardian's Email Address
Name of Individual Completing This Form
First Name
Last Name
Phone Number of Individual Completing This Form
(###)
###
####
Current Color Photo ID
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Social Security Card
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Birth Certificate
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Guardianship Award Letter, if applicable
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Current Individual Service Plan (ISP)
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Color Copy of EBT Card (including PIN Number)
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Medicaid Card
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Most recent PAYCHECK STUB (to be reported to Social Security)
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Completed/ Signed Direct Deposit form for wages into bank account
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Current signed lease
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
NOTARIZED Stable Account Documentation (Faithful Transport has a Notary as part of our team, by appointment only))
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Copy of current paperwork for Trust, Insurance, Retirement, Burial, etc.
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Current copy of bills (Example: Health Insurance, water, gas heating, electric, cable, internet, etc.)
FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files
Are you interested in more information regarding a STABLE account
Yes
No
INCOME / Expenses
Current INCOME (check all that apply)
Wages
Social Security (SSA)
Supplemental Social Security (SSI)
Supplemental Social Security Disability (SSDI)
SNAP
EBT
Current Rent Costs
(If you do not know, put N/A)
Electric Company Name
Electric Company Account Number
Water Company name
Water Company Account Number
Sewer Company Name
Sewer Company Account Number
Landline Phone Company Name
Landline Phone Account Number
Primary Pharmacy Name
Primary Pharmacy Account Number
Primary Pharmacy Phone Number
Residential Gas/Heating Company Name, if applicable
Residential Gas/Heating Company Account Number, if applicable
Thank you!
