Fiscally Sponsored Program- DRF

Disbursement Request Form

Please complete this form when requesting General Program Disbursements. Each payee requires a form - you may not include multiple payees on one form. Processing takes 7-10 business days. Clear electronic copies of invoices and receipts must be included (bank and credit card statements are not accepted). Submission of these documents is done within this form. You may upload either jpg, png, or pdf file types. If you have any questions or require assistance, please email

*If documents are not sent electronically, a $50 submission fee is added.*

1. General Information:

Program Name:

Account #:

Phone #:  

2. Payable to:

3. To send the check to a different address, which incurs additional fees, please insert information below:

4. Total Requested: $  

5. Special Processing & Delivery: OPTIONAL - Additional fees apply. (Skip this section if not applicable)



6. Direct Payment or Reimbursement Request 



Total Amount


Detailed Description

Ex. Reimbursement:




Food for Weekend Backpacks

Ex. Direct Payment:



Jane Smith

Books to be sent to TJ Middle School






Upload Receipts in either jpg, png, or pdf:

7. Event Name (If Applicable):  

Date of Event:  

8. Check Memo: (35 characters max)   

9. Program Manager Attestation Statement:

I certify that none of the above-named payees is a donor to my Program, nor does any donor have any advisory privileges as to my Program or the investments thereof. I further certify that none of the above persons is a family member of a donor to my Program (this includes spouses, siblings (by the whole or half-blood), and their spouses, children, grandchildren, great grandchildren and spouses of children, grandchildren, or great grandchildren). If the named payee is an organization, I certify that no donor to my Program, nor any person related to the donor, owns 35% or more of such organization directly or indirectly. United Charitable's Board of Directors reserves the right for final approval. If requesting an advance, please note that any funds not reconciled in a calendar year will be deemed taxable income to me and I will receive a 1099 Misc. for tax reporting purposes. 



Leave this empty:

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Signature Certificate
Document name: Fiscally Sponsored Program- DRF
lock iconUnique Document ID: a31cd567d1bcc1b1a27ea123abfc626306d73d8d
Timestamp Audit
November 4, 2020 12:24 pm ESTFiscally Sponsored Program- DRF Uploaded by Fiscal Sponsorship - IP
November 4, 2020 3:05 pm ESTIsaac Leeth - added by James Thomas - as a CC'd Recipient Ip:
November 4, 2020 4:55 pm ESTIsaac Leeth - added by James Thomas - as a CC'd Recipient Ip:
November 4, 2020 4:57 pm ESTIsaac Leeth - added by James Thomas - as a CC'd Recipient Ip:
November 13, 2020 2:44 pm ESTIsaac Leeth - added by Fiscal Sponsorship - as a CC'd Recipient Ip: