Payment Request Form

In order that Grace may accurately record and authorize all request for disbursements,please complete all information indicated and attach relevant documentation to substantiate your request. Although this process may seem overly burdensome, it is necessary to maintain effective internal control and avoid potential audit exceptions.

Name of person submitting form*

First NameLast Name

Email of person submitting form*

example@example.com

Phone Number (Mobile) of person submitting form

Area CodePhone Number

This payment request is

Payment to a Vendor for an invoiceReimbursement to me for an expense already madePrepayment to me for anticipated expensePayment to someone elseDocumentation for an office check already written

Vendor Name

Vendor Email (skip if not known)

example@example.com

Vendor address to mail check if different than attached invoice

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

My address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Payee Name

Other Payee Email (skip if not known)

example@example.com

Other Payee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Ministry leader or Staff person overseeing this request*

If you are not the ministry leader or staff person who can authorize/oversee this request, please indicate their name here.

Office Check # issued if applicable

If you don't know the account numbers for your ministry items, please check the list here or contact the office if you don't see appropriate account # on list.

Expense #1

Expense #2

Expense #3

Expense #4

Expense #5

Expense #6

If you need more to enter more than 6 expenses, you will start another form after submitting this one.

Total of All Expenses - Total Amount for Payment*

NOTE: The following file types may be attached for documentation of your expense(s):

jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx, csv, txt, rtf, html

Attach an invoices, receipt images, etc. here

Browse Files

Multiples files in same location can be selected for upload at same time.

More attachments?

Browse Files

Use this if you have other attachments from different locations on your computer/device

More attachments?

Browse Files

Use this if you have other attachments from different locations on your computer/device

If you have more files you need to attach, you may need to split your submission into another form, or email the additional files with notes to grace@gracedover.com and explain what submission they go with. Thanks!

Comments - Notes - Other Instructions