Distribution Request Form Beneficiary name * Is this a preapproval? * Yes No Amount Requested Or Not To Exceed Amount Reason for Request * If yes, how often does this bill occur? Due Date MM DD YYYY Will the payment amount stay the same? (If no, you need to send an invoice before each payment can be made) No Yes Make Check Payable to Mailing Address Account Number YOU MUST INCLUDE THE PROPER PAPERWORK AS BACKUP TO THIS REQUEST. I acknowledge as part of my request to receive money from my account: 1. All purchases must be made for the sole benefit of the Pooled Trust Member. These funds are not to be used to purchase goods or services for others. 2. The Trust is not responsible to advise me in regard to the impact of any request I make in relation to any benefits I receive. The receipt or payment of money from the Trust does not constitute a finding by the trust that the same will not impact my benefits. 3. I acknowledge that I am obligated to follow all rules related to any benefits I receive and I am solely responsible to notify and or repay any agency providing me benefits of any Trust payments that violate any such rules. 4. I will immediately provide receipts to the Trust for each and every use of funds I request and understand the Trust may in its sole discretion terminate further payments on my behalf if I fail to provide any such receipts or otherwise fail to comply with applicable trust rules. Name of Person Submitting this Request Phone Number (in case we have questions) Thank you, your request has been submitted!
