Payment Request

Name: Family Tree Surrogacy Center, LLC
Address: 2305 Historic Decatur Road, Suite 100, San Diego, CA, 92106
Telephone: +1 619-271-4093

FTSC Payment /Check Request Form (DUE BY THE 15th, 3pm No Exceptions)

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)
MM
DD
YYYY
Gender
Monthly Expense Allowance for the month of:
Amount
Multiples Monthly Expense Allowance for the month of:
Amount
Embryo Transfer Date
MM
DD
YYYY
Amount
Support Group/Event for the month of:
Amount
CODE WORD*
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
MM
DD
YYYY
Amount
OB / Hospital Co-Pay / Deductible Reimbursement 2
Receipts Required
MM
DD
YYYY
Amount
OB / Hospital Co-Pay / Deductible Reimbursement 3
Receipts Required
MM
DD
YYYY
Amount
Prescription Reimbursement 1
Receipts Required
MM
DD
YYYY
Amount
Prescription Reimbursement 2
Receipts Required
MM
DD
YYYY
Amount
Prescription Reimbursement 3
Receipts Required
MM
DD
YYYY
Amount
Mileage Reimbursement
MapQuest Required
Reimburse a trip?
Date trip 1
MM
DD
YYYY
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
MM
DD
YYYY
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
MM
DD
YYYY
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
Miscellaneous
Amount
TOTAL AMOUNT DUE
Upload receipts*
Drop files here or
Signature
Any address/phone changes, comments:
Email
Enter your email below if you'd like to receive a copy of this payment request

Payment Request

FTSC Payment /Check Request Form (DUE BY THE 15th, 3pm No Exceptions)

BMI Calculator