PCAN Check Request Form
Pensacola Community Action Network, Inc.
Project Name
Please Select
350 Pensacola
Bike Pensacola
Forest Floor Wilderness Programs
HerCode
Nature Connect
Pensacola CAN
Pensacola Children's Business Fair (PCBF)
Pensacola Network of Black Professionals (PNBP)
Scene Pensacola
Silver Initiatives
The Bridge to Health Project
Therapeutic Riding Unlimited
Three Pines
Project Name
*
Date of Request
*
-
Month
-
Day
Year
Date
Amount Requested
*
Check Payable to
*
Who should write the check?
*
PCAN should write the check
The bank should write the check
I (Project leader) will write the check
Where to send the check?
*
Address on attached invoice
Address entered below
Address to Send Check
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Purpose
*
Is this a fee for a professional service or independent contractor? (artists, police, etc.)
*
Yes
No
Has the independent contractor received more than $600 this calendar year?
Yes
No
Has the independent contractor provided a W-9 form? https://www.irs.gov/pub/irs-pdf/fw9.pdf
Yes (attach below)
No
Other
Is this payment using funds from a specific grant? IF YES: Please provide the name of the grant.
*
If NO, type NO
Person Requesting's Name
*
Email (we will send a copy of this form to you for your records)
*
example@example.com
Person Requesting's Signature
*
Please attach Receipts, Invoices, Check Image, or other documentation
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