Third-Party Payee Authorization
Authorize a third party to submit monthly program fee payments on behalf of a RAD Supportive Living resident.
Resident Information
Resident Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Room / Unit #
*
Third-Party Payee Information
Payee Name (Individual or Agency)
*
Contact Person (if agency)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Mailing Address
*
Payment Authorization
Monthly Program Fee Amount (USD)
*
Authorization Period
*
Ongoing (until revoked in writing)
Temporary (specify end date)
Temporary End Date
-
Month
-
Day
Year
Date
Acknowledgments
Signatures
Resident Signature
*
Resident Signature Date
*
-
Month
-
Day
Year
Date
Third-Party Payee Signature
*
Third-Party Payee Signature Date
*
-
Month
-
Day
Year
Date
RAD Supportive Living Representative Signature
*
Representative Signature Date
*
-
Month
-
Day
Year
Date
Submit Authorization
Submit Authorization
Should be Empty: