Wage Initiative Reimbursement Form

Please complete this form to receive next month's payment.

Connect with the MMDC team for assistance at caroline.roberts@mmdc.org or jordan@mmdc.org. Call us at 989-772-2858. To connect with your resource center, go here https://greatstarttoquality.org/resource-centers/
License Number (please enter letters as all capital letters)
Business Name
Grant Month
Program Type
Upload one document (screenshot or PDF) to attest funds were used as intended such as: payroll report, bank transfer screenshot, Venmo/CashApp record, copy of a check or payroll receipt

Cancelof
By signing below, I acknowledge that I have read and understood these terms and conditions, agree to comply with them, and certify that all information provided is accurate.
For security, please black out or redact Social Security Numbers and personal bank account digits before uploading.
Any feedback from staff or yourself that you would like to share:
Should be Empty:

Please complete this form to receive next month's payment.