Request For Disbursement Form
This form must be completed (A-G) before submitting to the Disbursement Committee for processing. For additional information contact the church office @773.873.4433
A. Payee Name, Address, City, State
B. Amount
Check Number
1
2
3
4
Total Amount of Disbursement
Type of Disbursement
Service
Reimbursement
Donation
W-9 needed for service
C. Date of Request
-
Month
-
Day
Year
Date
D. Date check is needed
-
Month
-
Day
Year
Date
E. Disbursement Requested by
First Name
Last Name
F. Ministry/Activity Name & ID Number
G. Reason for Request and/or Special Instructions
H. Disbursement Committee’s Action
Name
Date
APV
Not APV
Service Quality
Cleanliness
Responsiveness
Friendliness
I. Disbursement Committee Comments:
Submit
Should be Empty: