Funds Disbursement Form

Name *

First

Last

Email *

Your Fund Number *

Your 4 digit fund number (I.e. DFXXXX)

Payment Type *

Personal Disbursment Information

Personal Disbursement Type *

ACH/EFT to U.S. bank account
U.S. Wire Transfer
International Wire Transfer
Check by mail

NOTE: If choosing wire transfers or ACH please be sure you have also submitted the necessary authorization form available on your dashboard.

Disbursement Options *

Expense Disbursement/Reimbursement
Payroll Disbursement (tracked against 1099-NEC)

Reason for Funds Disbursement *

Please add a detailed request for disbursement here. Include items for reimbursement, project disbursement needs, etc.

Vendor Payment Information

Vendor Name

Vendor Phone

Vendor/Payment Email *

Vendor/Payee Address *

Address Line 1

Address Line 2

City

State

Zip Code

Upload Copy of Invoice (if available)

Click or drag a file to this area to upload.

If invoice is not available to attach, please enter invoice number if available.

Vendor Payment Type *

ACH/EFT (U.S. Banks Only)
Wire Transfer
Check

Bank Transfer Information

Click or drag files to this area to upload. You can upload up to 2 files.

Please attach wire transfer information for ACH or Wire. We will need Bank name, routing, account, and/or SWIFT codes. The document also must include name and address of account beneficiary for regulatory compliance. This info can normally be provided by the vendor.

Additional Info

Amount *

Total

$0.00