Zumbro House, Inc.
If you are receiving Social Security benefits (SSI or RSDI) please list your current representative payee: Name of Payee: Address: Phone #: Would you like Zumbro House, Inc. to become your representative payee (there is no fee for this service): YES. NO. Paying Child Support: YES. NO. Do you pay a spend down to a provider: YES . NO. If YES ... ................
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