ContractThird-Party Administration Agreement • November 22nd, 2017
THIRD-PARTY ADMINISTRATION AGREEMENT Protected (when completed) - To be handled by authorized personnel only. I, of, print name address agree to act as a trustee for Print Recipient's Name with the understanding that Social Assistance towhich he/she is eligble will be issued to me on his/her behalf and that I agree to make a report substantiated with reciepts, upon request by the Administering Authority showing the manner in which the Social Assistance was spent for the benefit of the recipient and dependent( Recipient's Date of Birth MM/DD/YY Recipient's S.I.N. X Signature of Recipient Date X Signature of Trustee Date X Signature of Witness Date Approved by: Print Name X Signature of Social Development Worker Date Original to Client file Copies to client and third-party administrator NSD-05