Disbursement Request Form Instructions - The Arc of Texas

SECTION 1
Account Info
SECTION 2
Disbursement Info
THE ARC OF TEXAS - MASTER POOLED TRUST
DISBURSEMENT REQUEST FORM INSTRUCTIONS
PLEASE READ CAREFULLY BEFORE COMPLETING A DISBURSEMENT REQUEST FORM
Name on Account: The account beneficiary’s name
Trust Account #: The Arc account number assigned to the beneficiary on the joinder.
Date: the date you are submitting the request
Item/Service Description: provide a brief description of how the money will be used for the
disbursement (example: furniture, storage fee, phone bill) Please itemize your request.
Amount: For each item or group of items, please put the amount to be paid.
Total Amount: Add up all
SECTION 3
Benefits
Please indicate if you are receiving SSI, Medicaid or SSDI. Check all that apply. For
recipients of SSI, please indicate that the request is not for food, shelter or cash as SSA can
reduce your benefits.
SECTION 3
Payee Info
If you are requesting the payment to be sent by check, complete Part A. If you are requesting
the payment to be sent by direct deposit to a bank account, complete Part B. For clarity, do
not fill out both.
PART A
Payee: the name of the person/store/company to whom the check should be made.
Memo on Check: indicate what information you want printed on the check (example: account
number for phone bill, patient ID for hospital, invoice number for furniture store)
Mail Check to:
Name: The name of the individual/store/company to whom the check should be sent.
Address: the address of the person/store/company receiving the check
OR
PART B
Checking: check this box if it is a checking account
Savings: check this box if it is a savings account
Bank Name: name of the financial institution
Bank Phone #: the phone number of the financial institution
Acct Holder’s Name: the name of the person who holds the account
(should be exactly as it appears on your bank statement)
Routing #(ABA): the 9-digit number designating the financial institution (ask the bank or look
on the bottom of any of your checks)
Acct #: the bank account number for this account
Requested by: the signature of the person submitting the request. (an electronic/typed signature is ok if sent from the
primary representatives email address)
Phone Number: a contact phone number for the requestor
Be sure to submit receipts, invoices, or proof of purchase with the form; otherwise,
the request will be delayed in processing.
You can submit the form in 3 ways:
Mail: The Arc of Texas, Attn: MPT, 8001 Centre Park Dr., Suite 100, Austin, TX 78754
Fax: (512) 454-4956
Email: trust@thearcoftexas.org
For additional forms, call us or visit our website
http://www.thearcoftexas.org/trust (Click on Forms & Documents)
If you have questions, please call Haley Greer, Dee West or Byron Dickard at
1-800-252-9729 or (512) 454-6694

THE ARC OF TEXAS – MASTER POOLED TRUST PROCEDURES
Disbursement Request Processing Overview
By Mail (3-5 days)
Request Form
→
By Fax or Email (1-2 days)
Processed and sent to the bank within 2
business days. Requests are sent to the
bank at the end of each day to be processed
the following day.
Check sent by mail (3-5 days)
Disbursement received
Direct Deposit (ACH- 1-3 days)
JPMorgan processes request
and prints check or sets up
electronic check (1 day)
TOTAL PROCESSING TIME: Check (7-10 days) Direct Deposit (3-5 days)
Check Deposits take 7-14 days to process.
Please keep this in mind when sending in checks for deposit
Important Facts
If you are mailing your request, send us COPIES of the receipts. Please DO NOT SEND the
following:
Original payment stubs, order form, payment envelopes (The Arc will NOT forward these
since only the check is sent by JPMorgan Chase Bank)
Original receipts/invoices (Make a copy to send to us and keep originals for your records)
For security reasons, DO NOT give disbursement forms to unauthorized people.
Do not sign blank forms.
If the check has not been received 10 days from mailing (from the bank) a stop payment
can be ordered and a new check can be issued.
If you have a recurring bill for the same amount every month, an automatic disbursement
can be set up to send a check on the same day of the month.
Please send in a disbursement request and indicate that an automatic payment should be
made.
Don’t forget to inform us of change of e-mail, address and phone number!
Still have questions Contact Haley Greer, Dee West or Byron Dickard
at 1-800-252-9729 (512) 454-6694 or email trust@thearcoftexas.org