Quad Cities Community Foundation - Financial Information Form
This questionnaire will guide organizations and individuals to the completion of necessary information to receive funds from the Quad Cities Community Foundation.
Are you responding as an Organization or Individual?
*
Organization
Individual
If you are an Organization, what type?
Business Organization
Non-Profit Organization or Governmental Entity
Would you like to be paid via ACH?
*
Yes
No
ACH Credit Authorization Agreement
Please provide all required details.
Individual or Organization Name
*
Legal Payee Name
Name of Payment Contact Person
First Name
Last Name
Title of Payment Contact Person
(if applicable)
Contact Number
*
Format: (000) 000-0000.
Payment Confirmation Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Development Officer (if different from above)
First Name
Last Name
Development Officer Email
example@example.com
Acknowledgement
I hereby authorize the Quad Cities Community Foundation to initiate credit entries to account indicated below at the depository financial institution named below and to credit the same such to such account. The QCCF will notify the receiver of the error and reason for reversal. I acknowledge that the origination of ACH transactions to our account must comply with the provisions of US law.
Bank Name
Transit Routing Number
Account Number
Account Type
Checking
Savings
I am authorizing QCCF to process payments to the above mentioned account.
Authorization
First Name
Last Name
Authorization
Title
Date
/
Month
/
Day
Year
Date Picker Icon
Required Document Submittal for ACH payment
A copy of a voided check or letter from your bank providing confirmation of your account details must be submitted with this form. Please ensure the documentation provided matches the information provided above.
File Upload: Voided check or bank letter is required for all payees wishing to be paid via ACH.
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W-9
If you are an individual or a business receiving payment from the Quad Cities Community Foundation, you are required to complete a W-9.
You can find the latest version of the W-9 template
here
.
File Upload: Completed W-9 form is required for individuals and businesses (excluding non-profits).
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of
Submit
Non-Profit Not Being Paid by ACH
Non-profit organizations that do not want to be paid via ACH do not need to complete this form.
QCCF Internal Only Questions
Profile ID
Verbally confirmed?
Yes, by whom, on what date
Date entered into QCBT
-
Month
-
Day
Year
Date
Date approved by VP Finance
-
Month
-
Day
Year
Date
Should be Empty: