PO Box 612, New Britain, CT 06050
Rev. 3/2012
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.
Name of Fund Administrator
