Local Full Name *

First Name

Last Name

Does Local Receive SSI?

Yes

Have applied but am waiting for response

Applied but was denied

Have never applied

Do not want to receive SSI

Has your SSI determination letter been submitted to Southwind Fields?

Yes

No

I do not receive SSI

Representative Payee

If Local does not have a rep payee, leave blank

First Name

Last Name

Rep payee phone number

(###)

###

####

Is Local Currently Employed

Yes

No