Disbursement Request Form
Please complete this form when requesting General Program Disbursements. Each payee requires a form - you may not include multiple payees on one form. Processing takes 7-10 business days. Clear electronic copies of invoices and receipts must be included (bank and credit card statements are not accepted). Submission of these documents is done within this form. You may upload either jpg, png, or pdf file types. If you have any questions or require assistance, please email info@athletescharitable.org
General Information
Program Name:
*
Account #
Phone
*
Please enter a valid phone number.
Payable to:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Check Mailing Address
To send the checks to a different address, which incurs additional fees, please insert information below:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested Disbursement Information
Total Requested
*
Special Processing & Delivery: OPTIONAL - Additional fees apply.
Delivery
FedEx (Overnight)
ACH
Bank Wire
Direct Payment or Reimbursement Request
*
Upload Receipts in either jpg, png, or pdf:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Event Name and Date (if applicable):
Check Memo: (35 characters max)
Program Manager's Attestation
I certify that none of the above-named payees is a donor to my Program, nor does any donor have any advisory privileges as to my Program or the investments thereof. I further certify that none of the above persons is a family member of a donor to my Program (this includes spouses, siblings (by the whole or half-blood), and their spouses, children, grandchildren, great-grandchildren, and spouses of children, grandchildren, or great-grandchildren). If the named payee is an organization, I certify that no donor to my Program, nor any person related to the donor, owns 35% or more of such organization directly or indirectly. Athletes Charitable a division of United Charitable's Board of Directors reserves the right for final approval. If requesting an advance, please note that any funds not reconciled in a calendar year will be deemed taxable income to me and I will receive a 1099 Misc. for tax reporting purposes.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Signature
*
Powered by
Jotform Sign
Clear
Submit
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform