Maryland Family Assistance Funds
For Requesting Disbursements from the MASSB Foundation
(to be customized to justify the request and to identify the payor, with Schedule 1 being required for government year-end tax reporting):
Withdrawal Request Form: Dated _______ __, 20__
Mark Poerio, Trustee
103 Market Street
Annapolis, MD 21401
Re: Withdrawal of Funds
Please be advised that the Board of Directors for the _______ County Department of Social Services has duly approved resolutions authorizing and recommending to the Community Foundation the release of $______ from our [__short-term OR __endowment] account within the MASSB Foundation.
Our Board of Directors represents and covenants that the funds being disbursed will be used solely for the purpose of paying expenses associated with the following program that is consistent with the charitable purpose of the mission of the ____________ County Department of Social Services: _________________________. Specifically, the disbursement advances child protection or family preservation expenses, that are not otherwise governmentally funded, in the following way(s): ________________________________________________.
We certify that the financial information set forth in Schedule 1 is, to the best of our knowledge, true and accurate for tax reporting purposes. Note that applicable tax laws now require Schedule 1 in order for us to process a withdrawal request.
The funds being requested should be made payable to _____________, and should be mailed to the following person:
_______________________ <Street Address>
________________, _____ ________ <City, State, Zip>
Invoice #: ____________ <if applicable to facilitate payment>
Please send the undersigned an email (to _____________@____________.____) as confirmation of payment to the above.
Signature: _____________________ Signature: _______________________*
Printed Name: ______________________ Printed Name: _______________________*
* include 2nd signature only if local board adopts resolutions to require that for enhanced security.
[FORCE PAGE BREAK]
Schedule 1: Information about Disbursement Request
Category of Expense
(from Form 990 by Row #) Fundraising Expense Program (Services) Expense
22. Grants and Allocations $______________ $_______________
26. Salaries and Wages
30. Professional Fundraiser
31. Accounting Fees
32. Legal Fees
33. Supplies (including software) $______________ $_______________
35. Postage and Shipping $______________ $_______________
37. Equipment and Maintenance
38. Printing and Publishing $______________ $_______________
39. Travel (food, trips) $______________ $_______________
40. Conferences and Meetings $______________ $_______________
43. Other - Insurance
43. Other - Admin Fee (prog mgmt)