Grant Disbursement Form | Sterling Foundation Management

Note: Fields marked with an * are required.

Charity

Name of Charity *

Amount of Grant *

Charity Contact Person

Charity Phone Number

Charity Street Address

Charity Fax Number

City

State

ZIP

Employer (EIN) or Tax Identification Number

Date grant to be made by

Please allow at least one week

Other instructions, if any (e.g., which assets to be sold to raise cash; general or specific purpose of the grant; restrictions you want to place on the grant; etc.)

Grant Purpose

I request the above grant be made to the above charity. I hereby authorize my bank/brokerage firm/custodian/investment manager to make the funds available. I also understand that neither my Foundation nor I will be receiving anything of value in return for this contribution.

Do you have control over or are you in any way affiliated with this grantee? *

Yes No

If "Yes", please state your relationship with the grantee (e.g., you are a Board member, are married to a Board member, are a major donor, etc.)

By typing my name below, I certify the above statements to be true and correct to the best of my knowledge, and I authorize Sterling Foundation Management to process the grant disbursement request as indicated above.

Signature Name *

Signature Date *

Title

Foundation Name

Letter Preference

All grants to recipient grantees must be accompanied by an appropriate letter. Sterling will prepare the letter. At your option, you may sign the letter, or Sterling will sign the letter on behalf of your foundation. If you want Sterling to send the letter, you need do nothing further. If you prefer to sign the letter, we will send you the letter and grant check (if applicable), which you then send to the grantee. Please indicate your preference below:

Letter Preference *

Send the check and grant letter directly to the grantee contact person above

Send the check and grant letter to me

Send only the grant letter to me (since I will send it with the check I disburse)

Send the check and letter to the person indicated below

Name

Address

City

State

ZIP

Human Validation