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For people with intellectual and developmental disabilities

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ONLINE DISBURSEMENT REQUEST FORM 

  • Please remember to review the disbursement request instruction page before submitting this form.
  • If you prefer to submit a paper document via fax or mail, visit the Forms page to download available forms.
  • Requests for major purchases (vehicle/home) or vacation plans requiring multiple payments, may not be submitted online. Please visit the Forms page to download the appropriate forms for those requests.
  • IMPORTANT: Once the request is submitted, you will receive an email confirmation. Please reply to that confirmation email and attach any supporting documents, receipts, etc. that you may have to submit.

 

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Check ALL that apply
IMPORTANT: For beneficiary's receiving HUD housing assistance, recurring payments may adversely affect your housing benefits. If you have any questions, please contact our office.
IMPORTANT: SSI recipients may not receive any trust funds for the purpose of purchasing food or paying for shelter (e.g. rent, utilities, property taxes).
Describe the goods or services being purchased and the reason for your request.
Please enter the dollar amount being requested.

Payee Information

Checks can NOT be made payable to the trust beneficiary.
Name
Street Address
City
State
Zip

Online Purchase Information

By selecting the Online Purchase Request option, you are indicating that you would like the OSNT staff to complete a purchase online for you and have the items shipped to you or held at the store for pick-up. If that is not your intent, then please go back and select the "Single Disbursement" option.
Copy and paste the website URL that you would like us to use to complete the purchase.
At which store would you like to pick up your items?
Street Address
City
State
Zip Code

Item Details

ITEM DESCRIPTION (include item stock number, size, color, etc)
ITEM COST $

REQUESTOR INFORMATION

Requests may only be submitted by a person authorized on the beneficiary's account to request disbursements. We may contact you to verify this request.
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