1. $
NEIGHBORHOOD COUNCIL:
Name of Requester:
If yes, enter term:
Payable to:
City State Zip:
Email Address Contact Phone number
Public Benefit Statement (Description and Purpose of the expenditure):
Requester's Signature Date
$
$
Authorization Code:
NC Budget Category:
Remittance
Address:
Please complete the following information for the requester/Payee:
TREASURER'S Name Signature Date
2nd Signer's Name Signature
Neighborhood Council Funding Program
FUNDING REQUEST FORM
Please complete this for to request funding from a Neighborhood Council
REQUEST DATE:
Is this a request for an out-of-state vendor?
Amount Requested:
Are you a board membmer of this Neighborhood Council?
Is this a request for recurring payment?
Is this request a payment for services requireing a 1099?
NEIGHBORHOOD COUNCIL USE ONLY
DECLARATION
I,the Requester, understand that I am requesting public funds from the Neighborhood Council and that such funds are restricted under the
guidleines set forth by the Department of Neighborhood Empowerment. I declare that this funding request does not pose any potential conflict
of interest for any Board Member and will provide any documentation requested by the Department to authorize payment or review the
appropriateness of the request.
1st Lvl |date:
2nd Lvl |date:
DEPARTMENT USE ONLY
AUTHORIZATION CATEGORY:
Date
NPG CIP
Lease Sponsored Event
>$2,500 Advanced Payment
Contract
Yes
Yes
Yes
Yes
No
No
No
No
Approved
Denied
Approved for:
Amended for:
DENIED
