Future Care Community Pooled Trust Disbursement Request Form

For Future Care Trust Office Use:

Date Received:	Available Balance:

Date Payment Mailed:	______________________________Check Number:

Directions:	Complete all fields below, attach all supporting documentation to request, sign and return to office. All requests must include a full billing statement, invoice, receipt or price quote, lease or landlord statement. Incomplete requests will be returned to the requestor which may result in delayed processing time.

Please check the Trust type:	Allow 8-10 days for processing

☐First Party Spend Down Trust: ☐First Party Lump Sum Trust: ☐Third Party Lump Sum Trust:

Requested Date: Click or tap to enter a date.

(list the date you are completing this request)

Beneficiary Name: Click or tap here to enter text.

Requested by: Click or tap here to enter text.

(If other than Beneficiary, must be authorized in the Beneficiary Profile)

Request Purpose:Click or tap here to enter text. Request dollar amount: $Click or tap here to enter text.

Is this request for an automatic monthly payment? Check one: ☐Yes ☐No If yes, Start Date:Click or tap to enter a date.

Automatic payments MUST be the same amount every month. If funds are not in Trust account, payment will not be processed and mailed.

Make check payable to:	Click or tap here to enter text.

Mailing Address:	Click or tap here to enter text.

Signature: ____________________________________________________________________

Form must be printed, signed and returned to our office. Must be signed by Beneficiary or authorized person. By signing, you affirm the information provided on this request is accurate, the request falls within the parameters of the Trust policy and the requested item or service is for the sole benefit of the Trust Beneficiary)

Mail to: Future Care Planning Services	FAX: (585) 210-4048

Trust Department	Email: trustservices@futurecareplanning.org	1000 Elmwood Ave

Rochester, NY 14620