Request a Check

Please complete this form when requesting a check to an agency that includes payments on behalf of multiple clients/members. The check will be processed during normal business hours. C3CAP will let you know when your request is complete along with a confirmation number. You will need to include this confirmation number in the Notes/Comments field of the Service Request you submit in CLARA after the fact. DO NOT USE THIS FORM TO REQUEST PAYMENT ON BEHALF OF ONE CLIENT/MEMBER – PLEASE USE CLARA DIRECTLY INSTEAD.
Check Requester Information
Name*
First Last
Email*
Phone*
Department*
Check Information
Date Needed*
Date Format: MM slash DD slash YYYY
Payee*
Amount*
Memo Line*
Mailing Information
Attn:*
Company*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Notes/Comments

Check Requester Information