NOTE: Must comply with US Tax Code and IRS Regulations
The undersigned understands this is a request for disbursement only and does not constitute a commitment by or contract with the Foundation to disburse funds.
The undersigned agrees to obtain and provide to the Foundation any documentation and other information needed to verify use of any disbursed funds, as requested.
The undersigned agrees that any funds disbursed as a result of this request, but not used for the purposes set out in this request, must be returned to the Foundation.
ARE YOU READY TO SUBMIT THE FORM?
If so, click the "submit" button below. If not, click the "back" button in the bottom left corner to go back to your submission and make changes.