Representative Financial Assistance

This address will receive a confirmation email

Date

Name

Organization

Have you received financial assistance and/or supplies from CSi in the past?

Date(s) Assistance Received

For what purpose are you requesting assistance at this time? Please mark all that apply.

Disaster Relief Flood Fire Earthquake Hurricane Tornado Tsunami Monsoon Other

If other, please specify

Humanitarian Aid Shelter Building Materials Blankets, Shoes, or Clothing Personal Hygiene Items Household Items Mosquito Nets Religious Persecution Refugee Relief Other

If other, please specify

Medical Aid Medical Equipment Medicine

Amount Requested

Details of how funding and/or supplies will be used and an estimate of how many people the amount requested and or supplies will assist

Date the funds and/or supplies need to be received

Banking Information (For bank transfers, please include bank name, account number, routing number, and a physical address. For international wire transfers, please include bank name, account number, SWIFT code, and address.):

Since CSi is a separate entity, we are not able to request your Banking Information from UPCI Global Missions. If you require assistance from Global Missions to complete this form, please contact them directly for your Banking Information or to give them permission to forward your Banking Information to us

Bank Name

Bank Address

Account Number

Routing Number (Domestic Bank Transfer)

SWIFT Code (International Wire Transfer)

Once your request has been received by our office, it will be sent to the CSi Board for review. CSi understands that time is of the essence and we work to get requests answered as quickly as possible. You will be notified via a written letter or email within 7 days of receipt of your request.

Upon the approval of your request and your acceptance of the financial assistance and/or supplies from CSi, you commit to providing additional documentation of how the assistance was used (receipts and a detailed expense report), as required by the IRS.

I understand and agree to the terms above.

You will provide CSi with photographs and/or video footage of the distribution of the aid that CSi provided or projects using supplies that CSi provided. Photographs and video footage will be used for promotional purposes.

I understand and agree to the terms above.

Representative Financial Assistance

Description

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