2-1-1 Payee Application

Client Information

Services and Support

Are you currently receiving counseling services from a mental health provider?
Are you currently receiving counseling services from an agency for alcohol or drug issues?
Are you a client of the Fairfield County Board of Developmental Disabilities, DD?
Are you on probation or parole?

Housing, Guardian, and Medical Information

Do you have a legal guardian?

Family Physician

Psychiatric Doctor or Nurse

Income Information

Expenses

Expense Amount Due Date Last Paid
Rent or Mortgage
Rent/Homeowner Insurance
Electric
Household Gas
Water/Sewer/Trash
Home Phone
Cell Phone
Grocery (out-of-pocket)
Cable Television / Satellite
Internet Services
Vehicle Payment
Auto Insurance
Gasoline
Auto Maintenance
Doctor Visits
Health Insurance
Prescriptions
Medical Bills
Childcare
Child Support
Credit Cards
Laundry
Legal fees / Court fines
Other
Other

Agreement

By signing below, I confirm that all of the information in this application is correct. I give permission to Fairfield County 2-1-1 to contact any business or agency in regard to my accounts, expenses, or payments.

Office Use / Non-Fillable Text

Date Received: ____________________

Signature: ____________________

SSA787

SSA11