Herb Thomas & Associates
We provide results in a way that inspires and maintains trust.

HTA Client Forms

This online form is created for your convience. The information is securely faxed directly to our office.

You may also print out this PDF version PDF to be printed out and faxed to our office.

Original invoices and/or receipts from payee/creditors "must" be faxed or emailed with this form All disbursements must be payable to a 3rd party Please allow 5‐7 business days to process request to completion.

ALL REQUESTS WILL BE ACKNOWLEDGED UPON RECEIPT – PLEASE CONTACT US IF WE DO NOT ACKNOWLEDGE RECEIPT OF YOUR REQUEST (510)749‐8358.

online form

Today's Date
Client's Name
Requester's Name Relationship to Client
Requester's Contact Information
   
For Bill Payment: (One request per form)
Payee Name Payee Account
Payee Address Amount $
 
Reason for Payment:
   

Original invoices and/or receipts from payee/creditors "must" be emailed to
All disbursements must be payable to a 3rd party
Please allow 5–7 business days to process request to completion.

ALL REQUESTS WILL BE ACKNOWLEDGED UPON RECEIPT—PLEASE CONTACT US IF WE DO NOT ACKNOWLEDGE RECEIPT OF YOUR REQUEST (510)749-8358

   

For Item/Service Purchase: (One item per form)
Store/Website Name: Item or SKU#:
Store/Website Address: Amount $:
 
Contact Information:
Reason for Purchase: