PCAN Check Request Form
Pensacola Community Action Network, Inc.
Project Name
*
Date of Request
*
-
Month
-
Day
Year
Date
Amount Requested
*
Check Payable to
*
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
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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