Critical Needs Request – Welcoming the Stranger

Critical Need Funds Request Form

Note: This is only to be used by mentors who are active in WTS.

First Name *

Last Name *

Phone *

Email *

First Name *

Last Name *

$ Amount Requested *

Itemize below if multiple expenses

Description of critical need and timing of needed funds; how the stipend will be used *

Has mentee received Critical Needs funding in past 6 months? *

Yes

Don't Know

$ Amount Received *

Enter 0 if unknown

Efforts made to otherwise secure the funding

No Disbursement Info

I do not have the disbursement information at this time

Payee Name (Organization or Person) *

Organization or Person to which the check is made out

Payee Address *

Payee Address

City

State/Province

Zip/Postal

Account # or Description for check memo *

Recipient Same as Payee

Select this is if the Organization or Person to receive the check is the same as the Payee

Recipient Name *

Organization or Person to whom the check is mailed (not necessarily the payee)

Recipient Address *

Recipient Address

City

State/Province

Zip/Postal

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