Project | Program Name * Your project | program not listed and should be? Contact nicole.watts@hopeprint.org. Northside Cultural Heritage District Mesopotamia Haven Community Garden Beakilah The Living Room Her Village Go 'Cuse Go Gulfport Hopeprint Properties Cuse Culture InfiniteTones Name of Vendor to be Paid (must match W-9) * This form is for payments to be made directly to vendors, NOT reimbursement. If you are seeking reimbursement as a Member-Partner, go to https://www.hopeprint.org/reimbursementform First Name Last Name Funding Source * The grant or funding source these expense are being reimbursed from NYS Ags & Markets National Trust for Historic Preservation Excellus Blue Cross Blue Shield Northside TNT Funds Cuse Culture Designated Funds MGCNHA Heritage Communities EPA | MS Land Trust Properties Fund Other (denote below) Other Funding Source (if applicable) Amt to be Paid * Verify the amount towards the uploaded invoice that is to be paid corresponding with this request $ What is the vendor providing? * Select best fit category | If for more than one category, select all and list the breakdown below | Remember, we can only process payment for items that are within the donor/funders intent for the funds you have in your account Supplies | Materials Food | Beverage Contracted Services Rental Fees Event or Special Insurance Printing | Postage Submitter's Name * First Name Last Name Submitter's Email * By checking the boxes below, I verify the following: * All three boxes required to be checked I have sufficent funds in my designated account for this expense This request is an allowed expense by the funder/donor whose funds are paying for it (e.g. per grant agreement) I understand the payments will be processed in three business days unless otherwise noted (Note: Payments are not processed during Season of Rest and Reset, and all requests must be made by at least four business days before the start of Seasons of Rest and Reset in April, August, and December) Thank you!
