Disbursement Form

Guidelines for Disbursement

• The fund will cover out of pocket expenses up to $250.00 per person during our fiscal year (July 1 – June 30).
• An invoice/receipt/EOB must be provided with the request.
• The Board of Officers will review requests sent for larger amounts. Individuals may contact the fund for assistance via email or phone.
• Request MUST be Breast Cancer Survivor and medical related items.

    Fill out this form entirely before submission.

    By checking this box, I agree that I am the legal recipient, and all information on this form is correct.