Program: Branch:
Case name:
Case number:
Worker ID:
Designation of Authorized
Representative or
Alternate Payee
What is an authorized representative or alternate payee?
 Authorized representative – This person can act for you to
apply for benefits. This person knows your situation. They
can report changes. The Department of Human Services (DHS)
and Oregon Health Authority (OHA) can discuss your case with
the person you name.
 Alternate payee - This person will get a card that lets them
spend your benefits for you.
You can choose someone to be your authorized representative,
alternate payee or both. If you want this person to be both, mark
both boxes one (1) and two (2) and select benefit type(s).
I choose (first, last name):
Relationship to you:
to be my:

Authorized representative. I understand if I give this
person wrong or incomplete information so my household
gets too many benefits, I will have to pay back what I should
not have received.
This person is my authorized representative for:
All benefits
Food benefits only
Cash/medical/child care benefits only
Case name:
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
Authorized Payee. I understand this person has full access
to use my benefits. I cannot get those benefits replaced if
this person uses them without my permission.
This person is my alternate payee for:
All benefits
Food benefits only
Cash benefits only
Child care benefits only – (can not be a DHS approved child
care provider)
(Client signature)
(Date)
To cancel or change this authorization, call your branch office.
This section is required if you choose an authorized
representative for cash, medical benefits and child care
benefits. Authorized representative completes this section.
Authorized representative name (first, last)
Date of birth
Phone number
Address
City
State
ZIP code
By signing this form as the authorized representative, I understand
for cash and medical programs, I am liable for repayment of an
overpayment if I knowingly give incorrect or incomplete information
or withhold information resulting in an overpayment.
(Signature of authorized representative)
Case name:
(Date)
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Our discrimination policy
The Department of Human Services (DHS) and the Oregon Health
Authority (OHA) do not discriminate against anyone. This means
that DHS|OHA will help all who qualify and will not treat anyone
differently because of age, race, color, national origin, gender,
religion, political beliefs1, disability or sexual orientation2.
You may file a complaint if you believe DHS or OHA treated you
differently for any of these reasons. To file a complaint with the
state, you can call the Governor’s Advocacy Office at
1-800-442-5238 (TTY 711) or write to their office at:
Governor’s Advocacy Office
500 Summer Street NE, E17
Salem, OR 97301
Fax: 503-378-6532
Email: [email protected]
“Equal opportunity is the law!”
The United States Department of Agriculture (USDA) and the
United States Health and Human Services (HHS) are equal
opportunity providers and employers. Auxiliary aids and services
are available upon request to individuals with disabilities.
To file a complaint with USDA and HHS, please read the “Client
Discrimination Complaint Information” form (DHS 9001). You can
find this form in the “Information and Referral Packet” (DHS 6609).
1SNAP
clients are protected against political belief discrimination.
2Sexual orientation is protected by the State of Oregon, but not
federal laws.
Case name:
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This document can be provided upon request in alternate formats
for individuals with disabilities or in a language other than English
for people with limited English skills. To request this form in
another format or language, contact us at 503-378-3486, email:
[email protected] or 711 for TTY.
Case name:
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