Fiscal Sponsor Authorization to Release Payment Form

Use this form to request that Black Lives Matter New Hampshire remit funds from your fiscal account. Please be sure to provide appropriate documentation.

Date

YYYY

Name

Name of Authorized Individual submitting this form

First Name

Last Name

Email of Authorized Individual submitting this form

Fiscal Sponsorship Organization Name

Use the same name listed in Fiscal Sponsorship Agreement

Payee Name

Payee Number

(###)

###

####

Payee Email

Payee Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Amount

Purpose of Expense

Does this payment require BLM NH to have a W-9 for the payee on file?

Is the payee a contractor, freelancer, or consultant being paid more than $600? If so, BLM NH will need a W-9 from the payee.

Signature

Please Type Your Name as Signature of This Request