Payment Information Form

Please complete all required fields below so that we may process your grant reimbursement via direct deposit. All information is handled in strict confidence.

1 Recipient Information

First Name *

Last Name *

Organization / Entity Name (if applicable)

Mailing Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

2 Grant Details

Grant Name / Program *

Award Amount *

Grant Agreement / Reference Number

3 Direct Deposit Information

Name on Bank Account *

Financial Institution Name *

Account Type *

Bank Routing Number (ABA) * Found at the bottom left of your check

Bank Account Number *

Confirm Bank Account Number *

4 Certification & Authorization

I hereby certify that the information provided on this form is accurate and complete. I authorize Voices of Equity to initiate payment to the account indicated above. I understand that I am responsible for notifying Voices of Equity immediately of any changes to the information provided. I acknowledge that the grant funds disbursed are subject to the terms outlined in my grant agreement.

I certify that all information provided above is true and correct. *

I authorize Voices of Equity to deposit grant funds into the account listed. *

Signature (Typed Full Legal Name) *

Date *

Your banking and personal information is collected solely for the purpose of processing grant disbursements and will be stored securely in accordance with applicable data protection regulations.