ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
ILLINOIS STATE COUNCIL K OF C CHARITIES, INC.
2
3
Council Name & No.:
4
City:
5
Grand Knight:
6
Date:
7
Request Date:
8
9
REQUEST FOR DISTRIBUTION
10
Distribution requests are payable only to Intellectual Disabilities organizations who are approved by Illinois State Council K of C Charities, Inc and are registered Charitable organizations.
11
12
13
ACCOUNT BALANCE TO DISTRIBUTE: (Prior unspent balance + Line 5 of CURRENT Report Form)
14
15
ALL REQUESTS MUST INCLUDE COMPLETE MAILING ADDRESS
16
NAME OF ORGANIZATIONADDRESSAMOUNT
17
1Street:
18
City:
19
State: Zip:
20
2Street:
21
City:
22
State: Zip:
23
3Street:
24
City:
25
State: Zip:
26
4Street:
27
City:
28
State: Zip:
29
5Street:
30
City:
31
State:Zip:
32
6Street:
33
City:
34
State: Zip:
35
7Street:
36
City:
37
State:Zip:
38
8Street:
39
City:
40
State: Zip:
41
9Donation to Illinois Homes Loan Program (a program of Illinois State Council K of C Charities. Inc.)$0.00
42
DISTRIBUTION AMOUNT REQUESTED$0.00
43
GK Name:NEW BALANCE (Account balance listed above minus distribution amount requested]
44
Phone:minus distribution amount requested)$0.00
45
Email:
46
Include your Special Olympics donations on Supreme Form 10784
47
Mail These Checks to:
48
Name:
49
Title:
50
Address:
51
City, St, Zip:
52
NOTE: Completion of this form with Grand Knight name constitutes official endorsement of this request and authorizes Illinois State Council K of Charities, Inc. to prepare checks as requested above.
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100