FND Stipend Form (Monthly)
You are being provided a stipend for your work above and beyond your hired Mass General Brigham (Brigham and Women’s Hospital or Mass General Hospital) scope. To receive funding from the FND, you must be a US citizen or permanent resident. FND stipends are taxable to you, and you will receive a Form 1099 NEC - non-employee compensation for which you must report to the IRS. You will be responsible for federal and state taxes and self-employment taxes. Payments are directly deposited the last week of the month worked. If any questions, please contact LaShaunda Gayden and Janelle Weathers.
Grantee Name
*
First Name
Last Name
Phone Number
*
Please enter the best phone number.
Format: (000) 000-0000.
Email
*
Please enter personal email address.
Current Address (where checks should be mailed)
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Street Address
If applicable, enter apt, suite, unit, floor, etc.
City
State / Province
Postal / Zip Code
Forwarding Address (for tax purposes if different from above)
Street Address
If applicable, enter apt, suite, unit, floor, etc.
City
State / Province
Postal / Zip Code
Please upload required W-9 Form here.
*
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Monthly Grant Amount ($)
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FND Account
*
Please Select
Start Date
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-
Month
-
Day
Year
Typically the 1st of a month.
End Date
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Month
-
Day
Year
If not predetermined, leave blank.
Summary of work to be performed:
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Name of Bank
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Account #
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9-Digit Routing #
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Type of Account (check one):
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Checking
Savings
Please upload a copy of a voided check or digital copy of online banking information including routing and account numbers for verification.
*
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*
I attest that all transactions are valid.
Grantee Signature
*
Account Holder Signature
*
ARCND Co-Director Signature 1
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ARCND Co-Director Signature 2
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