Tennessee Council on Developmental Disabilities Authorized Payment Request

This form can be used to upload up to 20 documents containing receipts, invoices or other backup documentation for your check request. Make sure your images are complete and fully legible before uploading them. UCP cannot reimburse items that are incomplete or illegible. All requests are subject to approval by the Tennessee Council on Developmental Disabilities.

Please note that once you have completed this form, it will record your information and go to the beginning of the survey to allow for new or additional project entries. This isn't an error and you don't have to enter the same information again.

Question Title

* 1. This payment request is for

Partners in Policymaking

Scholarship Fund

Question Title

* 2. Name or Description of Approved Conference or Funded Activity

Question Title

* 3. Person entering information/submitting this check request

Name

Email Address

Phone Number

Question Title

* 4. I Am

Council on Developmental Disabilities Staff

Other Professional

Program Participant or Family Member

Other (please specify)

Question Title

* 5. Payee Name (Name on Check) and Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Question Title

* 6. Total $ Amount this Check/Reimbursement Request (amount and backup documentation must reconcile to the total of each item submitted in the next section).