Award Distribution Check Request

To request a distribution check please complete this form. Checks may take up to 14 days for processing. Please reference dropbox to review a copy of request and processed award. If this is a traditional scholarship, the check must be made out to the educational institution with the student’s name and/or ID number in the memo section of the check. If you have any questions, please contact Rachel Rohlen at [email protected].

Memorial Fund Name:*
Email*
Date*
MM slash DD slash YYYY
This award is for:*
- A Scholarship
- An Organization
EIN:
Name of Award Recipient/Organization*
Check should be made out to:*

Name / Payee
Check should be mailed to:*

Please let us know to who's attention the check should be mailed.
Address to Send Check:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Scholarship Recipient’s Email*
Scholarship recipient’s ID number:
Award Recipient’s Address(if applicable)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Award Amount: $*

Please use $ sign.
Indicate date needed:
Month
Day
Year
Note For Scholarship Recipient*
Please include a short note (or instructions) for the scholarship recipient or individual/organization receiving the award confirmation email. This note will be included in the confirmation email the recipient receives when the award is processed.
Scholarship Description, Any Special Instructions
Briefly describe the recipient and the selection process. Also include any information CharitySmith should know prior to issuing the check.
Memorial Fund Administrator Consent*
I attest that the award recipient is not related to me, by blood or marriage, or a friend.
Printed Name*
First Last
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Phone
This field is for validation purposes and should be left unchanged.