Brockport Foundation Disbursement Form

Division of Advancement
finance@brockport.edu
585-395-2451

Banner ID (if applicable)
Payee Name
Type of Disbursement
Payee Mailing Address Payee Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please fill out the details for each invoice/receipt that are included in the total amount to be disbursed. If this is for meals, please include all the names of those who attended.
Description of Disbursement
Amount
Description of Disbursement

Only complete if there is more than one receipt/invoice being included in the disbursement.
Amount

Only complete if there is more than one receipt/invoice being included in the disbursement.
Description of Disbursement

Only complete if there is more than one receipt/invoice being included in the disbursement.
Amount

Only complete if there is more than one receipt/invoice being included in the disbursement.
Make sure the total amount to be disbursed ties to the total of all the invoices/receipts.
Total Amount to be Disbursed
Fund Number-Fund Name
Account Number-Account Name
Amount
Fund Number-Fund Name

Only needed if there are multiple funds or account numbers that need to be charged.
Account Number-Account Name

Only needed if there are multiple funds or account numbers that need to be charged.
Amount

Only needed if there are multiple funds or account numbers that need to be charged.
Please upload any receipts for reimbursement. If requesting a bill be paid, please upload the corresponding invoice.
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)

If this is for an event, please attach a copy of the event flier and those who attended from Brockport.
Special Mailing Instructions/Notes

If there are none, please leave this blank.
Requestor Requestor First Last
Requestor Email
Requestor Signature: Type your full name as legal representation of your signature.
Approver

Brockport Foundation Disbursement Form

Please fill out the details for each invoice/receipt that are included in the total amount to be disbursed. If this is for meals, please include all the names of those who attended.

Make sure the total amount to be disbursed ties to the total of all the invoices/receipts.