LaLa Fiscal Sponsorship Distribution Form

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

In order to comply with IRS regulations, this form must be completed and returned to Midlands Community Foundation prior to each distribution.

Date*

Fund Name*

Address of Fund*

Authorized Contact Person*

Phone*

Email*

Authorized Signature of Fund*

Use cursor to sign in box below.

Total Amount Requested from Fund:*

Date Funding Required*

Distribution Check from Fund Made Payable to:

Name/Organization:*

Address*

City*

Zip Code*

State*

State

Special Instructions (if any):

Please provide a project title and brief description.*

Budget Category*

Identify which of the selection(s) criteria your project meets:*

Program/Project Expenses

Innovative Project

Urgent Funding

Capital Project

Partnerships

Volunteer Involvement

Challenge Gift

Seed Project

Please attach invoices, receipts, or other documentation for this payment. You must include vendor invoices with details, not statements.

File Upload

Drop files here or

Accepted file types: jpg, pdf, gif, png, doc, xls, Max. file size: 300 MB.

Distributions must include complete documentation, including signed contracts/agreements, invoices, and/or receipts attached to this form.
Distribution payments will be made 7-10 business days upon receipt of all documentation.
We recommend that you keep a copy of your completed Disbursement Request for future reference.
The fund will be responsible for any fees incurred due to stop payment requests, lost or misplaced checks, or errors or omissions in the submitted form.
If you have questions, please contact us at info@midlandscommunity.org or 402-991-8027.