Payment Request

Begin

FTSC Payment/Check Request Form
(DUE BY THE 15th)

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
OB Name (if applies)
Delivery Hospital (if applies)
Weeks Pregnant
As the first of the month (if applies)
Estimated Due Date (if applies)
Month
Day
Year
Gender
Monthly Expense Allowance for the month of:
Amount
Multiples Monthly Expense Allowance for the month of:
Amount
Embryo Transfer Date
Month
Day
Year
Amount
Support Group/Event for the month of:
Amount
Maternity Clothing
(onetime payment)
Amount
Singleton Pregnancy/Living Expense Compensation
Out of 10
Amount
Multiple Pregnancy/Living Expense Compensation
Out of 10
Amount
Housekeeping Allowance
(onetime payment)
Amount
Reimburse OB / Hospital Co-Pay / Deductible / Prescription?
OB / Hospital Co-Pay / Deductible Reimbursement 1
Receipts Required
Month
Day
Year
Amount
OB / Hospital Co-Pay / Deductible Reimbursement 2
Receipts Required
Month
Day
Year
Amount
OB / Hospital Co-Pay / Deductible Reimbursement 3
Receipts Required
Month
Day
Year
Amount
Prescription Reimbursement 1
Receipts Required
Month
Day
Year
Amount
Prescription Reimbursement 2
Receipts Required
Month
Day
Year
Amount
Prescription Reimbursement 3
Receipts Required
Month
Day
Year
Amount
Mileage Reimbursement
MapQuest Required
Reimburse a trip?
Date trip 1
Month
Day
Year
Amount
Reason trip 1
Roundtrip mileage trip 1
The first 50 miles are not reimbursed. Enter the total roundtrip mileage minus 50.
Reimburse a second trip?
Date trip 2
Month
Day
Year
Amount
Reason trip 2
Roundtrip mileage trip 1
The first 50 miles are not reimbursed. Enter the total roundtrip mileage minus 50.
Reimburse a third trip?
Date trip 3
Month
Day
Year
Amount
Reason trip 3
Roundtrip mileage trip 3
The first 50 miles are not reimbursed. Enter the total roundtrip mileage minus 50.
MapQuest Upload*
Drop files here or

Max. file size: 5 MB.
Miscellaneous
Amount
TOTAL AMOUNT DUE
Upload receipts*
Drop files here or

Max. file size: 32 MB.
Any address/phone changes, comments:
Your case manager*
- Chelsea Tipton-Lake
- Jessica Adams
Email
Enter your email below if you'd like to receive a copy of this payment request

Family Tree Surrogacy Center, LLC
2305 Historic Decatur Road, Suite 100
San Diego, CA 92106 USA

Phone: +1 (619) 271-4093
Email: info@familytreesurrogacy.com

Payment Request

Begin

FTSC Payment/Check Request Form
(DUE BY THE 15th)

Intended Parents

Egg Donors

Surrogates

Locations

Payment Request

Begin

FTSC Payment/Check Request Form (DUE BY THE 15th)

Intended Parents

Egg Donors

Surrogates

Locations

FTSC Payment/Check Request Form
(DUE BY THE 15th)