DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) Companion Home (CH) Client Individual Financial Plan (IFP) CLIENT NAME COMPANION HOME PROVIDER NAME REPRESENTATIVE PAYEE CH provider Self Other (list name / association): GUARDIAN None Full Guardian of estate only Partial, not guardian of estate name and contact information: If applicable, guardian’s Income OTHER MONTHLY DOES CH CLIENT REP GUARDIAN INCOME TYPE AMOUNT NOT PROVIDER OTHER (LIST) MANAGED PAYEE MANAGED (IF ANY) HAVE MANAGED MANAGED SSI $ SSA $ VA $ Paycheck / wages $ Other (specify): $ Other (specify): $ Management of Resources OTHER MONTHLY DOES CH TYPES OF ACCOUNTS / CLIENT REP GUARDIAN AMOUNT NOT PROVIDER OTHER (LIST) RESOURCES MANAGED PAYEE MANAGED (IF ANY) HAVE MANAGED MANAGED Checking account $ Savings account $ Other bank account (describe): $ Prepaid credit / debit $ card Cash personal – $ spending Cash hygiene $ – Gift cards $ Trust account $ Burial Plan $ Other (specify – may include $ retirement funds, stock, vehicles, etc. Other (specify – may include $ retirement funds, stock, vehicles, etc.
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) Companion Home (CH) Client Individual Financial Plan (IFP) CLIENT NAME COMPANION HOME PROVIDER NAME REPRESENTATIVE PAYEE CH provider Self Other (list name / association): GUARDIAN None Full Guardian of estate only Partial, not guardian of estate If applicable, guardian’s name and contact information: Income INCOME TYPE MONTHLY AMOUNT (IF ANY) DOES NOT HAVE CLIENT MANAGED CH PROVIDER MANAGED OTHER REP PAYEE MANAGED GUARDIAN MANAGED OTHER (LIST) SSI $ SSA $ VA $ Paycheck / wages $ Other (specify): $ Other (specify): $ Management of Resources TYPES OF ACCOUNTS / RESOURCES MONTHLY AMOUNT (IF ANY) DOES NOT HAVE CLIENT MANAGED CH PROVIDER MANAGED OTHER REP PAYEE MANAGED GUARDIAN MANAGED OTHER (LIST) Checking account $ Savings account $ Other bank account (describe): $ Prepaid credit / debit card $ Cash – personal spending $ Cash – hygiene $ Gift cards $ Trust account $ Burial Plan $ Other (specify – may include retirement funds, stock, vehicles, etc. $ Other (specify – may include retirement funds, stock, vehicles, etc. $