DIDD Katie Beckett Payment Request Form
Participant Information
DIDD Number
Child First and Last Name:
*
First Name
Last Name
Parent First and Last Name
First Name
Last Name
Parent Phone Number
Please enter a valid phone number.
Parent/Child Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Date of Birth:
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Non-Binary
Decline to Answer
Region
*
Payment Request Details
Decision Making Supports Information Education Session
Do you have an entry for Decision Making Supports IES?
Yes
Total Amount
Make Payment Payable To:
Payment Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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of
Health Insurance Counseling/Forms Assistance
Do you have an entry for Health Insurance Counseling/Forms Assistance?
Yes
Total Amount
Make Payment Payable To:
Payment Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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Choose a file
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of
Decision Making Supports - Lawyer Fees
Do you have an entry for Decision Making Supports Lawyer Fees?
Yes
Total Amount
Make Payment Payable To:
Payment Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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of
Family Caregiver Education and Training
Do you have an entry for Family Caregiver Education and Training?
Yes
Total Amount
Make Payment Payable To:
Payment Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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of
Individual Education and Training
Do you have an entry for Individual Education and Training?
Yes
Total Amount
Make Payment Payable To:
Payment Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
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of
Additional Expense(s)
Do you have an entry for an Additional Expense?
Yes
Expense Category
Please Select
Decision Making Supports Information Education Session
Health Insurance Counseling/Forms Assistance
Decision Making Supports Lawyer Fees
Family Caregiver Education and Traning
Individual Education and Training
Total Amount
Make Payment Payable To:
Payment Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information/Special Instructions
Supporting Documentation / Vendor W9 / ACH Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
KB Case Manager Information
Please enter the contact information for the person completing this request
KB Case Manager First and Last Name
*
First Name
Last Name
KB Case Manager Phone Number
Please enter a valid phone number.
KB Case Manager Email
*
Confirmation Email
Confirmation Email - a copy of this request will be sent to this email address
KB Case Manager Signature
*
Staff Signature/Submission Date
*
/
Month
/
Day
Year
Date
Submit
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