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Disbursement Request Form

Use this convenient online form to request a disbursement from your OSNT account, and submit supporting documentation. Before completing a disbursement request, please remember to review the DISBURSEMENT INSTRUCTIONS page for detailed information that may effect your request.

GENERAL INFORMATION

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Last
Required for ABLE account transfer requests.
Check ALL that apply
IMPORTANT: For Full Balance transfer requests, the following requirements MUST be met:

  • The OSNT sub-account must be a first-party account
  • The OSNT sub-account balance must be less than $5,000
  • The OSNT sub-account must be active, with at least four (4) disbursements requested within the prior 12 months OR the sub-account beneficiary shows a need to use the funds for basic needs not eligible for disbursements through the OSNT such as rent, utilities, or food
  • The beneficiary 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
  • The beneficiary or authorized representative must acknowledge the disclosures listed below.
IMPORTANT: For Partial Balance transfer requests, the following requirements MUST be met:

  • The OSNT sub-account beneficiary must demonstrate a need to use the funds for basic needs not eligible for disbursements through the OSNT such as rent, utilities, or food
  • The beneficiary 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
  • The beneficiary or authorized representative must acknowledge the disclosures listed below.
IMPORTANT: SSI recipients may not receive any trust funds for the purpose of purchasing food or paying for shelter (e.g. rent, utilities, property taxes).
IMPORTANT: For beneficiary's receiving HUD housing assistance, recurring payments may adversely affect your housing benefits. If you have any questions, please contact our office.
Describe the goods or services being purchased and/or the reason for your request.
Please enter the dollar amount being requested.

Maximum file size: 2.1MB

Please upload a copy of any documentation needed for your request. Acceptable formats are jpeg or PDF.

PAYEE INFORMATION

Checks can NOT be made payable to the trust beneficiary.
Name
Street Address
City
State
Zip

ONLINE PURCHASE INFORMATION

By selecting the Online Purchase Request option, you are indicating that you would like the OSNT staff to complete a purchase online for you and have the items shipped to you or held at the store for pick-up. If that is not your intent, then please go back and select the "Single Disbursement" option.
Copy and paste the website URL that you would like us to use to complete the purchase.
At which store would you like to pick up your items?
Street Address
City
State
Zip Code

Items to Purchase

Please enter information on the items you would like to purchase. You may add additional items (up to 10 total items) by clicking the Add Item button.
(include item stock number, size, color, etc)
plus1 Add Item minus1 Remove Item

ABLE Transfer Disclosures/Acknowledgement

  • The OSNT sub-account will retain current fees related to closing an account
  • The OSNT sub-account will be closed
  • If the beneficiary wants to use an OSNT sub-account in the future, a new account must be opened, and the full enrollment fee paid to establish a new account
  • The OSNT is not responsible for monitoring, documenting, or reporting any activity in the person’s ABLE account
  • The OSNT is not responsible for any adverse effects on a beneficiary’s means-tested benefits based on use of funds once they are deposited into the ABLE account
  • The OSNT is not responsible for monitoring, documenting, or reporting any activity in the person’s ABLE account
  • The OSNT is not responsible for any adverse effects on a beneficiary’s means-tested benefits based on use of funds once they are deposited into the ABLE account
By submitting this form, I acknowledge and accept the OSNT disclosures listed above. *

REQUESTOR INFORMATION

Requests may only be submitted by a person authorized on the beneficiary's account to request disbursements. We may contact you to verify this request.
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The Arc Oregon logo

The Arc Oregon
2405 Front Street NE #120  |  Salem, OR 97301
Phone  (503) 581-2726  |  Fax  (503) 363-7168 

Oregon Special Needs Trust Logo
The Arc Oregon logo

The Arc Oregon
2405 Front Street NE #120  |  Salem, OR 97301
Phone  (503) 581-2726  |  Fax  (503) 363-7168 

Oregon Special Needs Trust Logo
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