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

Verification of Authorization to Request Funds*

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

Beneficiary Living Arrangements*
SSI Recipient*
Medicaid Recipient*
Medicaid Waiver Recipient*
Update Contact Information*
Phone

Disbursement Request

Type*

Purchasing a Vehicle

Please complete the GCT of BDI Vehicle Purchase Request Form.


True Link Card Requests

Must provide all previous receipts before a new funding request can be processed.


ACH Direct Deposit or Check or Wire Transfers

Is this a new Bank Account?
Account Type*

Bill Pay

Bill Pay Frequency*

STABLE (ABLE) Account Transfer Request

  • Must provide documentation showing deposits into the ABLE account for the current calendar year to confirm the transfer will not exceed the maximum annual deposit amount allowed for ABLE accounts ($17,000).
  • Must provide all documentation including receipts, quotes, invoices, and/or estimates to be eligible for deposit.
  • Advisory Co-Trustee is responsible for reporting all utilization of funds to the Social Security Administration.
  • GCT of BDI is not responsible for monitoring, documenting, or reporting any activity of ABLE accounts.
  • GCT of BDI is not responsible for any adverse effects on the beneficiary’s means tested benefits based on the use of funds once they are deposited into the ABLE account.

Describe the intended purchase, list vendor names and amounts, provide copies of any quotes for services, or other form of verification.


Request for Distribution

Receipt Submission

Distribution Request Type*

Please note household expenses must be divided by the number of individuals living in the home.

Vehicle Owned by Trust

I verify that the caregiver timesheet is attached.

Drag and drop files here or

Signature

By signing below the signatory certifies the following:


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


  • the requested disbursement is for the sole benefit of the Beneficiary.


  • The information in this request form accurately reflects the amounts for services and goods for the sole benefit of the Beneficiary.


  • I will pay back to the trust any expenses found to be duplicates, not for the benefit of the Beneficiary, or incurred after the death of the Beneficiary.


  • I will follow SSI/Medicaid rules for reporting changes to the Beneficiary’s financial situation within 10 working days (SSI/Medicaid recipients only).


By checking below, I do hereby attest that this information 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.