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Shared Horizons, Inc. Trust and Fiduciary Services for Individuals with Disabilities
REQUEST FORM
Shared Horizons, Inc.
FROM: _____________________________________________________________
DATE: ________________________________
RE: Request for Disbursement from Trust
The following request is being made to the Wesley Vinner Memorial Trust:
Beneficiaries Name: ___________________________________________
Expenditure: ___________________________________________ ___________________________________________
$__________________________________________ qReceipt Attached qInvoice Attached
Check Payable to: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________
Special Instructions: ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Please remit request to the information below.
_____________________________________________________ _____________ Signature Title Date
5335 Wisconsin Avenue, NW, Suite 910 s Washington, D.C. 20015 202-448-1460 s 202-448-1461 FAX |