If there is no guardian, please have the client complete and sign this letter to authorize the change.
Mail all information to:
Fiscal Assistance, Inc.
124 West Holum Street
DeForest, WI 53532
Complete a FA New Client Enrollment Form. Make sure all applicable fields are completed.
Have physician/medical officer complete and sign an SSA form 787 “Physician’s/Medical Officer’s Statement of Patient’ Ability to Manage Benefits”.
If the client has a guardian, please have the guardian complete and sign this letter authorizing this change.
OR fax to 608-846-3412
Please read and sign the Client Agreement document confirming you read and agree with the terms of FA becoming your rep payee
If you have a client that may need a payee you can click the tab “Who Needs a Payee” or you can find additional resource information at the SSA website. If it is determined that the client does need a payee the following steps outline the process for obtaining a payee.
Please complete and sign the Consent to Release Information in order for FA to obtain and/or exchange information for the purpose of planning for your well-being