Grant Disbursement Request Form

For Donor Advised Funds

Fund Information

Name of Fund

Advisor Information

Advisor

First Name

Last Name

Phone Number

Please enter digits only (no special characters). Example: 9014540034

Number of Disbursement Requests

Grant Disbursement Recipient #1

Recipient Name

Amount Recommended

Please enter amount without commas or periods/cents. Example: 1000 (for $1,000.00)

Special Instructions or Designation

Grant Disbursement Recipient #2

Recipient Name

Amount Recommended

Please enter amount without commas or periods/cents. Example: 1000 (for $1,000.00)

Special Instructions or Designation

Grant Disbursement Recipient #3

Recipient Name

Amount Recommended

Please enter amount without commas or periods/cents. Example: 1000 (for $1,000.00)

Special Instructions or Designation

Confirmation

Total Grants Recommended

Please enter amount without commas or periods/cents. Example: 1000 (for $1,000.00)

Statement of Release

I understand that the final approval of my grant recommendations rests with the Grants Committee whose charge it is to see that all grants are within charitable purposes of the Foundation, and that I will be notified of the Committee's actions. I do not expect any tangible benefits from the agencies listed above as a result of this (these) grant recommendations, and these recommendations do not represent payment of a personal pledge or any other financial obligation.

Grant Disbursement Request Form

For Donor Advised Funds

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