SCH04 Scholarship Disbursment Form (With Dropdown Fields)

SECTION 1: Student Information
Last Name
Click here to enter text. / First Name
Click here to enter text. / M.I.
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Student I.D. #
Click here to enter text. / Telephone Number
Click here to enter text. / Cell Phone Number
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Permanent Home Address (street, city, state, zip code)
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SECTION 2: Scholarship Information
Scholarship Name
Click here to enter text.
University of Connecticut Accounting Office KFS#
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Accounting status has been verified as active and has sufficient funding for the award. Yes No
The University of Connecticut Foundation # Click here to enter text. Department Number: Click here to enter text.
The scholarship is a President’s Challenge Award. Yes No
TERMS OF AWARD/SCHOLARSHIP/PRIZE
Semester (Year) Amount
Fall
Spring
Summer
The award is intended for reimbursement of student expenses related to research, study abroad, etc. Yes No
Note: attach documentation or related expenses
PROVIDE ANY SPECIAL REQUESTS FOR THIS SCHOLARSHIP IN THIS FIELD (attach additional documentation as appropriate)
Click here to enter text.
Prepared By Date
E-mail Address
Department Phone Unit
SECTION 3: Signature/Certification
To the best of my knowledge, I certify that the above request for disbursement is consistent with all pertinent University of Connecticut and UConn Foundation policies and procedures.
Primary Signature ______Date______
Secondary Signature______Date______
SECTION 4: Office Use
SFAS ______Date______
Item Type ______