Donation Disbursement Authorization Form
Organization Information
Organization Name
Contact Person
Phone Number
Email Address
Disbursement Details
Date of Request
Total Amount Requested
Purpose of Disbursement
Check/Wire Payee Name
Payment Method
Check
Bank Transfer
Other
Breakdown of Requested Amount
Description
Amount
Supporting Documentation
List attached documents (invoices, receipts, etc.)
Authorization
Authorized Signature
Date
Printed Name
Title/Role