Pooled Trust Disbursement Error Report Form – Center for Disability Rights

Name of Person Reporting Issue*
First Last
Name of Consumer (If different from person reporting issue)*
First Last
Name of Vendor who was paid*
Problem with Disbursement (Check One)
- Duplicate Payment
- Incorrect Amount Paid
- Incorrect Trust Sub-Account (not my bill)
- Incorrect Vendor
- Unauthorized Payment
- Other (Please explain below)
Issue
Please briefly provide a summary of your issue in reference to the Pooled Trust.
Your email (please provide your email that you use to communicate with the Trust)*