Request for Fiscal Agent Distribution

Request for Fiscal Agent Distribution

This form must be completed in order to request distribution of funds where the Merion Village Association is acting as the fiscal agent. Please allow 15 days for processing.
Name of Person Completing This Request*

First NameLast Name
E-Mail Address of Person Completing This Request*

Confirmation EmailA copy of this request will be sent to you via e-mail.
Date by Which Funds are Needed*

DayMonthYear
15 day processing window
Name of Payee*
The name of the payee EXACTLY as it should appear on the check.
Total Amount Requested*
Breakdown of purchases for which reimbursement is requested. Please add a new line for separate dates and or vendors.*
Receipts / Supporting Documentation*

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Upload all receipts related to this request. The total amount requested cannot exceed the purchases shown in the breakdown above and the receipts uploaded. The MVA cannot distribute funds without supporting documentation showing proof of payment.
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