Disbursement form
A disbursement form authorizes payment to be made to a given party.
The form_type parameter DISBURSEMENT_FORM for the Upload PDF endpoint is required for this form type.
Learn more about how we process disbursement forms here.
Optional fields captured
Field data attributed directly to the disbursement form is captured as Form Data objects, each one keyed off the following attribute names.
Configuration-driven output
All fields below are optionally captured, depending on your order form. To adjust fields captured, please speak with your Ocrolus Account Manager.
| JSON Attribute | Data Type | Description |
|---|---|---|
disbursement_form-Part1-Member:memberName | Text | Member name |
disbursement_form-Part1-Member:memberId | Text | Member ID |
disbursement_form-Part1-Member:methodSent | FAX,MAIL,EMAIL | Method sent |
disbursement_form-Part1-Member:sentFrom | Text | Sent from |
disbursement_form-Part1-Member:specialInstructions-CircleOne: | Multiple Choice | ADDRESS CHANGE ACCOUNT # CHANGE MAIL TO DIFFERENT ADDRESS OVERNIGHT ADDRESS |
disbursement_form-Part1-Member:specialInstructions-IncludeInstructionsHere: | Text | Special instructions |
disbursement_form-Part2-Disbursement1:bill1-AccountNumber | Text | Bill 1 - account number |
disbursement_form-Part2-Disbursement1:bill1-Desciption | Text | Bill 1 - description |
disbursement_form-Part2-Disbursement1:bill1-CheckPaybaleTo | Text | Bill 1 - check payable to |
disbursement_form-Part2-Disbursement1:bill1-BillingAddress:addressLine1 | Text | Bill 1 - address line 1 |
disbursement_form-Part2-Disbursement1:bill1-BillingAddress:addressLine2 | Text | Bill 1 - address line 2 |
disbursement_form-Part2-Disbursement1:bill1-BillingAddress:city | Text | Bill 1 - address city |
disbursement_form-Part2-Disbursement1:bill1-BillingAddress:state | Text | Bill 1 - address state (formatted 2 character state code) |
disbursement_form-Part2-Disbursement1:bill1-BillingAddress:zip | Text | Bill 1 - address ZIP Code (formatted 5 digit code) |
disbursement_form-Part2-Disbursement1:bill1-BillAmount | Money | Bill 1 - Bill amount |
disbursement_form-Part2-Disbursement1:bill1-AmountToBePaid | Money | Bill 1 - amount to be paid |
disbursement_form-Part3-Disbursement2:bill2-AccountNumber | Text | Bill 2 - account number |
disbursement_form-Part3-Disbursement2:bill2-Desciption | Text | Bill 2 - description |
disbursement_form-Part3-Disbursement2:bill2-CheckPaybaleTo | Text | Bill 2 - check payable to |
disbursement_form-Part3-Disbursement2:bill2-BillingAddress:addressLine1 | Text | Bill 2 - address Line 1 |
disbursement_form-Part3-Disbursement2:bill2-BillingAddress:addressLine2 | Text | Bill 2 - address Line 2 |
disbursement_form-Part3-Disbursement2:bill2-BillingAddress:city | Text | Bill 2 - address City |
disbursement_form-Part3-Disbursement2:bill2-BillingAddress:state | Text | Bill 2 - address state (formatted 2 character state code) |
disbursement_form-Part3-Disbursement2:bill2-BillingAddress:zip | Text | Bill 2 - address ZIP Code (formatted 5 digit code) |
disbursement_form-Part3-Disbursement2:bill2-BillAmount | Money | Bill 2 - bill amount |
disbursement_form-Part3-Disbursement2:bill2-AmountToBePaid | Money | Bill 2 - amount to be paid |
disbursement_form-Part4-Disbursement3:bill3-AccountNumber | Text | Bill 3 - account number |
disbursement_form-Part4-Disbursement3:bill3-Desciption | Text | Bill 3 - description |
disbursement_form-Part4-Disbursement3:bill3-CheckPaybaleTo | Text | Bill 3 - check payable to |
disbursement_form-Part4-Disbursement3:bill3-BillingAddress:addressLine1 | Text | Bill 3 - address line 1 |
disbursement_form-Part4-Disbursement3:bill3-BillingAddress:addressLine2 | Text | Bill 3 - address line 2 |
disbursement_form-Part4-Disbursement3:bill3-BillingAddress:city | Text | Bill 3 - address city |
disbursement_form-Part4-Disbursement3:bill3-BillingAddress:state | Text | Bill 3 - address state (formatted 2 character state code) |
disbursement_form-Part4-Disbursement3:bill3-BillingAddress:zip | Text | Bill 3 - address ZIP Code (formatted 5 digit code) |
disbursement_form-Part4-Disbursement3:bill3-BillAmount | Money | Bill 3 - bill amount |
disbursement_form-Part4-Disbursement3:bill3-AmountToBePaid | Money | Bill 3 - amount to be paid |
disbursement_form-Part5-Disbursement4:bill4-AccountNumber | Text | Bill 4 - account number |
disbursement_form-Part5-Disbursement4:bill4-Desciption | Text | Bill 4 - description |
disbursement_form-Part5-Disbursement4:bill4-CheckPaybaleTo | Text | Bill 4 - check payable to |
disbursement_form-Part5-Disbursement4:bill4-BillingAddress:addressLine1 | Text | Bill 4 - address line 1 |
disbursement_form-Part5-Disbursement4:bill4-BillingAddress:addressLine2 | Text | Bill 4 - address line 2 |
disbursement_form-Part5-Disbursement4:bill4-BillingAddress:city | Text | Bill 4 - address city |
disbursement_form-Part5-Disbursement4:bill4-BillingAddress:state | Text | Bill 4 - address state (formatted 2 character state code) |
disbursement_form-Part5-Disbursement4:bill4-BillingAddress:zip | Text | Bill 4 - address ZIP Code (formatted 5 digit code) |
disbursement_form-Part5-Disbursement4:bill4-BillAmount | Money | Bill 4 - bill amount |
disbursement_form-Part5-Disbursement4:bill4-AmountToBePaid | Money | Bill 4 - amount to be paid |
Sample form
The below Ocrolus sample PDF (input) matches the below sample JSON result (output).
drive.google.comSample JSON result
{
"status": 200,
"message": "OK",
"response": {
"forms": [
{
"tables": [],
"form_config_pk": 3629,
"uuid": "e68667af-f6f9-4889-bf59-080a44c82afb",
"form_type": "DISBURSEMENT_FORM",
"pk": 10587757,
"raw_fields": {
"disbursement_form-Part2-Disbursement1:bill1-CheckPayableTo": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "YOGURT INDUSTRIES",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-CheckPayableTo": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-AmountToBePaid": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-AccountNumber": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part1-Member:specialInstructions-IncludeInstructionsHere:": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-AmountToBePaid": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-BillAmount": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-BillingAddress:state": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-AccountNumber": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-Description": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "AUTO SCENT",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-AccountNumber": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "53648561",
"page_doc_pk": 87761462
},
"disbursement_form-Part1-Member:specialInstructions-CircleOne:": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-BillingAddress:addressLine2": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-BillingAddress:addressLine1": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-BillingAddress:addressLine1": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "750 MIDDLE COUNTRY ROAD",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-BillingAddress:addressLine2": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-BillingAddress:city": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part1-Member:sentFrom": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "ALVARO JEFFRY",
"page_doc_pk": 87761462
},
"disbursement_form-Part1-Member:memberName": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "JAMES ROBERT",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-AccountNumber": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-BillingAddress:city": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-BillAmount": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-CheckPayableTo": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-CheckPayableTo": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part1-Member:memberId": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "AF2486",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-BillingAddress:zip": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "11953",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-Description": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-BillingAddress:zip": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-BillingAddress:state": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "NY",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-BillingAddress:city": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "MIDDLE ISLAND",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-AmountToBePaid": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-Description": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-BillingAddress:zip": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-BillingAddress:addressLine2": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part5-Disbursement4:bill4-BillingAddress:addressLine1": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-BillingAddress:addressLine1": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-BillingAddress:addressLine2": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-AmountToBePaid": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "167.80",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-BillingAddress:state": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-Description": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part1-Member:methodSent": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "EMAIL",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-BillingAddress:city": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-BillAmount": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part2-Disbursement1:bill1-BillAmount": {
"is_empty": false,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "167.80",
"page_doc_pk": 87761462
},
"disbursement_form-Part4-Disbursement3:bill3-BillingAddress:zip": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
},
"disbursement_form-Part3-Disbursement2:bill2-BillingAddress:state": {
"is_empty": true,
"source_filename": "Sample 1 - Disbursement Form (1).pdf",
"alias_used": null,
"value": "",
"page_doc_pk": 87761462
}
}
}
],
"pk": 11534533,
"uuid": "cfc3806c-360b-490f-92e0-bd6b64076e3f"
}
}
Updated 7 months ago