Auto Payment Request Form

A budget audit must be performed and approved by a CTS trust administrator.
Please submit a copy of the past three months of bills to this vendor.
Please be advised that this payment may be considered In Kind Support and Maintenance.
It is your responsibility to disclose the payment of any utilities to your social security representative as this may cause up to a 1/3 reduction in your SSI benefit.

Email(Required)

Phone(Required)

Name(Required)

First Last

Trust Account Number(Required)

Estimated Monthly Expense(Required)

Pay Type(Required)

Physical Check

Online Payment

Other

Payee Name(Required)

Payee Address(Required)

Street Address Address Line 2 City State ZIP Code

Website(Required)

Username(Required)

Password(Required)

Account Number(Required)

Reason for Distribution(Required)

Date(Required)

Electronic Signature

File

Max. file size: 50 MB.

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