Stateline Sports Group Fundraiser Payout Form

Stateline Sports Group Fundraiser Payout Form
Date/Time/Submitted
When completing this form, please remember that for anyone we need to pay, we must have their full name, full address, and the amount they won.

If you have more than eight winners, simply complete an additional form.
Team Name*

10U Sutherland12U Marszalec12U Holbert14U Clutter15U DeMoss15U McNames16U Corbo/Badgley18U Smith18U Head
Person Submitting*

First NameLast Name
Email*
example@example.com
Describe the Fundraiser*
Pay Out # 1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Pay Out # 2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Pay Out # 3

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Pay Out # 4

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Pay Out # 5

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Pay Out # 6

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Pay Out # 7

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Pay Out # 8

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Check Distribution*

Please mail The ChecksWe will distribute the checks
Should be Empty: