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Master Trust Fund Dis Req 11 20 08doc by HC120807101231

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									                                                        MASTER TRUST FUND
                                                         CHECK DISBURSEMENT REQUEST
                                                                        Complete all areas




SERVICE CENTER:                                                                                               COUNTY :

CLIENT NAME:                                                                                         DATE OF BIRTH:                    /          /

CLIENT SSN:                        -          -

PAYEE:                                                                                       AMOUNT REQUESTED: $

PAYEE ADDRESS:
                                                      Street Address                                         City                             State      Zip Code


ITEMS TO BE PURCHASED (If more space is needed please attach a separate sheet of paper)
Requested items/services       Amount or vendor quote                     Requested items/services                                 Amount or vendor quote




I am requesting the above purchase(s) to be made from my trust account. I understand that this request must be approved, and any changes must be
approved. I also understand that the original receipt, or receipts and cash, totaling the amount of the check must be returned.


 Client Signature                                                Date

   JUSTIFICATION if client cannot sign:


SIGNATURES BELOW INDICATE APPROVAL OF THE REQUEST:
I certify that the goods/services requested are for the current needs of the client referred above. Additionally, I understand that any changes to this request are
permitted only with the written approval of all authorized officials. Furthermore, it is understood that original receipts, or receipts and cash, totaling the check
amount, must be returned to the DCF Budget and Financial Management Office within 15 days of the check date.



 Case Manager Signature                       Printed Name                                   Telephone       e-mail address                              Date



 Case Manager Supervisor                      Printed Name                                   Telephone       e-mail address                              Date



 Authorizing CBC Agent Signature                      Printed Name                                           Telephone             Date



PAYMENT AUTHORIZATION BY FINANCE OFFICE

_______________________                ______________            ________________________________________________________________
Account Type                            MTF Balance              Reason for Denial if any

___________________________ __________________ _________________                              __________________________________ _______________
Prepared by                 Check #            Check Date                                     Mailed to / Received by            Date:

								
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