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
MASSB Foundation
103 Market Street
Annapolis, MD  21401

            Re:       Withdrawal of Funds

Dear Mark:

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:

Payee: ___________________________

_______________________ <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.

Best regards,

Signature:        _____________________             Signature:    _______________________*        

Printed Name: ______________________            Printed Name: _______________________*

*  include 2nd signature only if local board adopts resolutions to require that for enhanced security.


Withdrawal Request

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)                 $______________                         $_______________
34. Telephone
35. Postage and Shipping                           $______________                         $_______________
36. Occupancy
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)