Clackamas County Money Management Program (MMP) Spending Request Form

This form is used for requesting funds outside of the client’s spending plan.

For questions or assistance, please contact us at ommp@clackamas.us or 503- 650-5623.

Client Name

Description of purchase(s)

Amount requested

Vendor purchase receipts are required if amount is $200 or more.

Payable to:

Client

Vendor/Volunteer/Caregiver/Other

Requires Payee Disbursement Receipt signed by Client and returned to our office.

Name

Delivery Options

Mail

Pick-up

Fund debit card

Name

Address

Address 2

City

State

ZIP

Pick up at our office during normal business hours.

This information is to be filled out by the person submitting the request.

Name

Phone

Other Information

TIMELINE: Requests submitted before Monday at 8 a.m. will be processed for payment on Wednesday of the same week. If client has a debit card, it will be funded the following Monday. For requests received after the deadline, the funds will be processed the following week.

I will submit the Payee Disbursement Receipt, signed by Client, to the office within 30 days.

I will work with client to ensure that vendor receipts are submitted to office.

I hearby certify that the information provided in this form is complete, true and correct to the best of my knowledge.

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Clackamas County Money Management Program (MMP) Spending Request Form

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