To request a distribution check please complete and submit this form. You will be notified of your distribution approval by email and will receive a check within 14 days. If this is a 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—please provide the correct information accordingly. If you have any questions please contact Stacey Spain at [email protected].

Date:

Memorial Fund Name:

Memorial Fund Administrator:

Memorial Fund Administrator Address:

Email:

Award Information:

This award is for a scholarshipThis award is for an organizationThe organization is a 501c3 nonprofit

If the award is going to a 501c3, please provide EIN#:

Award Recipient Name:

Award Recipient Address:

Address to Send Check To:

Award Amount:

Award Check Should Be Written Out To:

Scholarship Recipient's ID Number (if applicable):

Rush? ($10 fee, priority mail faster processing)

yesno

Briefly describe the scholarship recipient and the selection process:

By checking below, I attest that the award recipient is not related to me, by blood or marriage, or a friend.

I attest

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