Grant Award Benefit Disbursement Authorization Form
Recipient Information
Full Name
ID / Employee Number
Email Address
Phone Number
Mailing Address
Grant Information
Grant Name
Grant ID / Reference
Award Amount
Purpose of Disbursement
Disbursement Details
Disbursement Method
Direct Deposit
Check
Other
Bank Details / Payee Information
Authorization
Authorization Statement
Recipient Signature
Date
Authorized Staff Signature
Date