PCAN Check Request Form
Pensacola Community Action Network, Inc.
Project Name
*
Date of Request
*
-
Month
-
Day
Year
Date
Amount Requested
*
Check Payable to
*
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
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: