SPEF - Disbursement Request

Grant Information

Disbursement Request
Grant To:
Legal Entity Name
To Be Used For:

Other
Description of Educational Impact Achieved by Funds
Upload invoices, quotes, schematics, or other proof of desired improvements

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Scholarship Information

Disbursement Request
Name of Scholarship
Description of Criteria for Scholarship
Why is this individual receiving the scholarship?

Other
Upload Proof of GPA, Essay Submission, etc

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Must Upload Student Identification Card

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Scholarship Payable To:
Name of Host Institution
Recipient Name

First NameLast Name
Recipient Phone Number
Format: (000) 000-0000.
Recipient Email
Name and address for check to be sent?
Do you need certificates?
Where do certificates need to be sent?
Please enter Email for digital certificates or Physical Address for printed certificates. NOTE: Printed certificates may take 4-6 weeks for distribution.

Submission

Disbursement Request
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.
Your Signature
Your Name

First NameLast Name
Title or Relationship to the Chapter?
Phone Number
Format: (000) 000-0000.
Your Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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General Information