CCSU Foundation, Inc. Disbursement Order
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CCSU Foundation, Inc. Disbursement Order PO Box 612, New Britain, CT 06050 Rev. 3/2012 Date: TO: Treasurer, CCSU Foundation, Inc. Payee: Address: City: State: Zip: which is attached hereto. Purpose: Amount Total: Please send signed Disbursement Order with documentation attached to: CCSU Foundation Office, Downtown Campus, 185 Main Street - Room 411, New Britain, CT 06051. Keep a copy for your records. (Supervisor's signature is required if Payee is the Fund Administrator.) Form 1099: [ ] Yes Disbursement Order prepared by: Telephone (ex. 860-832-2278) Project/Purpose For Foundation Use Only Fund API: Date: Check #: Individuals claiming reimbursements of expenses must submit a Reimbursement of Expense Report with Disbursement Order and attach receipts or other supporting documentation. Payments of stipends or honoraria must be accompanied by a signed personal services agreement with social security number, invoice or other supporting documentation. Please prepare a disbursement in the amount of: Approval of supervisor Signature of Fund Administrator Against invoice #: I certify that the above expenditure is properly due, has not been paid, and has been incurred for approved Foundation purposes. Debit Account No.
Transcript of CCSU Foundation, Inc. Disbursement Order
CCSU Foundation, Inc. Disbursement OrderPO Box 612, New Britain, CT 06050 Rev. 3/2012
Date:
TO: Treasurer, CCSU Foundation, Inc.
Payee:
Address:
City: State: Zip:
which is attached hereto.
Purpose:
Amount
Total:
Please send signed Disbursement Order with documentation attached to:CCSU Foundation Office, Downtown Campus, 185 Main Street - Room 411, New Britain, CT 06051. Keep a copy for your records.
(Supervisor's signature is required if Payee is the Fund Administrator.)
Form 1099: [ ] Yes
Disbursement Order prepared by: Telephone (ex. 860-832-2278)
Project/Purpose
For Foundation Use Only
Fund
API: Date: Check #:
Individuals claiming reimbursements of expenses must submit a Reimbursement of Expense Report with Disbursement Order and attach
receipts or other supporting documentation.
Payments of stipends or honoraria must be accompanied by a signed personal services agreement with social security number, invoice or other
supporting documentation.
Please prepare a disbursement in the amount of:
Approval of supervisorSignature of Fund Administrator
Against invoice #:
I certify that the above expenditure is properly due, has not been paid, and has been incurred for approved Foundation purposes.
Debit Account No.
gordonjo
Text Box
Name of Fund Administrator
