Fiscal Sponsor Authorization to Release Payment Form Fiscal Sponsor Authorization to Release Payment Use this form to request that Park Pride remit funds from your fiscal account. Please be sure to provide appropriate documentation. Date* MM slash DD slash YYYY Name of Authorized Project Liaison submitting this form* First Last Email of Authorized Project Liaison submitting this form* Fiscal Sponsorship Account Name*Payee Name*Park Pride can either reimburse a member of your Friends Group for expenses or pay a vendor directly.Payee Phone Number*Is this a reimbursement? Yes A reimbursement does not require a W-9 or Certificate of Insurance (COI).Does this payment require Park Pride to have a W-9 for the payee on file?*YesNoIs the payee a contractor, freelancer, or consultant being paid more than $600? If so, Park Pride will need a W-9 from the payee.Upload Payee W-9*Max. file size: 50 MB.Does this payment require Park Pride to have a Certificate of Insurance (COI) for the payee on file?*YesNoIs the payee is a third party vendor or contractor conducting work in the park? If so, the payee must provide a certificate of insurance to protect Park Pride from liability for injuries or damages.Upload Payee Certificate of Insurance*Max. file size: 50 MB.Preferred Method of Payment*ACH direct depositMailed checkA member of your Friends Group or a vendor can be paid either via a mailed check or ACH direct deposit.Does Park Pride have the payee's ACH authorization on file?*YesNoTo remit payment via ACH direct deposit, we must have an authorization form and voided check on file.ACH authorization form*Max. file size: 50 MB.The ACH authorization fillable PDF form is linked here.Voided check*Max. file size: 50 MB.Please upload a voided check for ACH payment.Address for check recipient* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Expenses to be reimbursed/paid*DateVendorDescriptionAmount Total Amount Requested*If your amount requested is DIFFERENT than the invoice, please explain why.Receipts/invoices* Drop files here or Select files Max. file size: 50 MB. Please upload a receipt or invoice for each expense listed above.Any additional information you would like to share?Signature of Authorized Project Liaison*NameThis field is for validation purposes and should be left unchanged.
