GCT of BDI Disbursement Request Form

  • ALL REQUESTS MUST BE FOR THE SOLE BENEFIT OF THE BENEFICIARY
  • ALL REQUEST FOR FUNDS MUST HAVE RECEIPTS AND/OR QUOTE FOR EXPENSES TO BE ELIGIBLE FOR REIMBURSEMENT/DISBURSEMENT
  • Incomplete requests will result in delayed processing time.
  • Requests will be processed within 10 business of receipt of request.
  • Depending on the request additional information may be required.
 

Person Making Request

 

I am authorized to make requests on behalf of the Beneficiary.


By checking below, I do hereby attest that I am authorized to make requests on behalf of the Beneficiary and that the information below is true, accurate and complete to the best of my knowledge and I understand that falsification, omission, or concealment of this information may subject the beneficiary to loss of SSI/Medicaid, and/or payback of funds to the beneficiary’s sub-account.

 

Please type your full name below.


DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

 
 

 

Beneficiary Information

 
 
 
 
 
 
 

 

Disbursement Request