Common use of Direct Deposit Clause in Contracts

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative PayeeXxxxx. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative PayeeXxxxx. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) _ _ . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account Admission Agreement (7/2015) at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) _ _ . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative PayeeXxxxx. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization( S p e c i f y N a m e o f P e n s i o n b e n e f i t o r g a n i z a t i o n ) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source( S p e c i f y N a m e o f t h e i n c o m e s o u r c e ) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) _ _ . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account Admission Agreement (7/2015) as Representative PayeeXxxxx. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) _ . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to Admission Agreement (7/2015) change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents Residents and all short-term residents Residents transferred to long-term care in the Facility may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” (“PNA”) deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative PayeeXxxxx. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o do the Facility’s addressFacility’saddress. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility Facility, and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . incomesource)_ I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” allowance in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative PayeeXxxxx. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative PayeeXxxxx. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative PayeeXxxxx. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.

Direct Deposit. All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes. _ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee. _ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. Admission Agreement (7/2015) (Specify Name of Pension benefit organization) _ _. _ I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address. (Specify Name of the income source) _ _ . I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at the Facility. I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated above or by submitting a check for such income or by turning over such income checks on a monthly basis on or before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand that I/the Resident is/are responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI. Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the Facility for the services rendered to the Resident pursuant to terms of this Agreement.