CCEA - Disbursement Request

Project Title

Authorized Project Representative (Your Name)

First NameLast Name

Type of legal entity receiving the funds?

Other

Donor & Amount

Donor NameAmount - before fees

What will you mostly be using these funds for?

How would you like your funds delivered?

For ACH, please fill out this authorization form if you haven’t already or if you need to update your account information.

To receive a wire, please fill out this form if you haven’t already or if you need to update your account information.

RUSH REQUESTS: all rush requests are subject to internal approval and must be submitted before 11am for same day transfers.

If you have not yet turned in a W-9 or if you would like the funds to be disbursed to a new US Tax ID #, please upload a W-9.

Bank Name

Bank Address

Name on Account

Address associated with this account

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone number associated with this account

Please enter a valid phone number.Format: (000) 000-0000.

Account Number

For Domestic US Wires

Wire Routing Number

For Domestic US Wires

Swift Code

For International Wires

IBAN

For International Wires

Funds received from this disbursement will only be used in accordance with the proposal previously approved by CCEA.

I understand that I am responsible for reporting any funds received through fiscal sponsorship to the IRS.

By checking the box below, I certify that I am current on all reporting due to CCEA. I understand that I am both legally and contractually responsible for reporting annually on any funds received through my fiscal sponsorship with CCEA and will file all required project reports and detailed financial accounting, including providing receipts upon request, for funds received from this disbursement