Revised 01/2016
DISBURSEMENT REQUEST FORM
(Fund name) (Account name)
Pay to:
Name of the payee for the check and
address to which the check is to be
mailed
Charitable Purpose of payment:
(i.e.: Grant, project expense including identification of project, meeting
expense, postage, supplies or other expense category)
Amount of payment
Please list each payment
separately.
Include sales tax.
Please attach ORIGINAL invoice, receipt or other documentation for this payment.
You must include vendor invoices with details; not statements.
Disbursement requests over $1,500 for community funds or $5,000 for organizational funds require two signatures.
Phone:
Submission Date:
Signature(s) of person(s) authorized by the Fund Advisory Committee to request disbursements
The disbursement must be for charitable purposes and to an allowable payee. If you have questions, please contact our
Accounting Staff before submitting at info@nebcommfound.org or 402-323-7330.
If you wish to have a check sent to your fund advisory committee for a special presentation, please note that clearly on the
form; otherwise, we will mail the check directly to the payee.
Disbursement Requests received by Monday with all necessary documentation and signatures will be paid by Friday of the
same week.
We recommend that you keep a photocopy of your completed Disbursement Request for future reference.
This form may be photocopied. It is also available on the NCF website at
http://www.nebcommfound.org/affiliated-funds/find-a-form/.
P.O. BOX 83107 * Lincoln, NE 68501-3107 * 402-323-7330
For Internal Use Only
Ck Date
Inv. #
Acct. Code
Description
Acct. Code
Description
Acct. Code
Description
Total $
1099
click to sign
signature
click to edit
![]()
