Program Hosting Funds Payment Submission Form

Program Hosting Funds Payment Submission

Use this form Program Hosting Funds requesting reimbursements or invoice payments.

"*" indicates required fields

Supporting Org/Fund Name*

Your Name*

Your Email*

Enter Email Confirm Email

Payee Name*

Have you previously submitted contact information related to this payee?*

Yes

Payee Address*

Street Address Address Line 2 City State ZIP Code

Relevant Information*

Do you have a detailed report listing each expense account code and funding source that you can upload?

Yes

Detailed Funding Report*

Please upload your report.

Drop files here or

Max. file size: 1 GB.

Expense Detail*

Please list expenses with the relevant detail requested. (Use the + icon to add more rows – one row for each expense).

Funding Source

Expense Account/Code

Description/Purpose

Amount

Total Amount:*

This is the total of all itemized expenses.

Receipt of Payment*

Forward check to payee listed above

ACH Payment (Direct Deposit)

Special Instructions (Please explain below)

Have you previously submitted bank information for this payee?*

Yes

ABA/Routing Number*

Bank Account Number*

Receipts/Invoice Upload*

Please upload a scan, photo, or otherwise digitally formatted (PDF files only please) receipt or invoice for each payment. Receipts or invoices are required for all payments.

Drop files here or

Max. file size: 1 GB.

Special Instructions

Please explain here if you have a special request for your payment. or if there’s anything else we need to know to process your request.

Approval*

By typing your name in this box, you certify that you are authorized to make payment submissions on behalf of the Fund stated above.

This field is for validation purposes and should be left unchanged.