Thank you for choosing our agency to provide residential services to . We are available as needed to assist with your money management needs including, but not limited to representative payee services. This is provided as a courtesy. However, as the conservator or authorized family member you may decline our assistance at which point you accept full responsibility for the money management responsibilities.

This letter serves to clarify the responsibilities of each party as it relates to their role in managing funds. Please indicate your choice below.

I authorize Betterlives LLC as the representative payee. As the representative payee, we agree to assist the service recipient in managing the finances assigned to our agency on behalf of the service recipient. This may include monthly benefits as authorized through the Social Security Administration, Veteran's Administration, Railroad Retirement benefits, etc. The agency further agrees to:

• File paperwork with the proper entity to establish representative payee status.
• Provide assistance with opening a checking and/or savings account. Bank statements will be sent to the office for review and reconciliation.
• Assist the service recipient in managing monthly financial obligations including, but not limited to; rent, utilities, food, household supplies, and personal spending money.
• Ensure access to personal funds.
• Maintain detailed financial records with copies of receipts for expenditures. Records may be reviewed by appointment at the agency office during regular business hours.
• Report any changes in the service recipient's gross income, marital status, change of address, and/or employment changes. Additionally the service recipient, conservator and/ or authorized family member agree to provide the agency with timely notification of any changes that may have an impact on benefits. They further agree to hold the agency harmless if they are negligent in timely and factual reporting.
• Report earnings as required by SSA unless earnings are otherwise being reported by the employer.
• File the annual Representative Payee Report as required by SSA.

I do NOT authorize Betterlives LLC as the representative payee.

As the conservator, authorized family member or service recipient, I understand and agree:

• I must accept full responsibility to manage monthly financial obligations including, but not limited to; rent, utilities, food, household supplies, and personal spending money. These obligations must be met on a timely basis in accordance with the lease agreement and to avoid late fees.
• I agree to report any changes in the service recipient's gross income, marital status, change of address, and/or employment changes as required by SSA.
• Employees of Betterlives LLC not permitted to write checks or manage money on behalf of the service recipient or representative payee.
• Employees of Betterlives LLC are allowed to assist the service recipient in managing personal spending money, but must do so in accordance with agency/DDA policies and procedures. All money received is recorded on a cash log. Expenditures are recorded and receipts are attached.
• File the annual Representative Payee Report as required by SSA.

This consent is renewed annually and shall remain in effect until the new consent is executed. The conservator authorized family member or service recipient may request a change in this agreement at any time.