Complete and submit this form to request payment for expenses or services

Once you have filled in this form, click the green “Submit” button. Then, wait until the next screen appears with a confirmation message indicating that your form has been successfully submitted. If the confirmation screen does not appear, it means that your request is incomplete, and you will need to make corrections or complete it and submit it again. If you have any questions, please call or email us

1 - WHO IS REQUESTING THIS PAYMENT?

First Name

Last Name

Phone

(###)

###

####

2 - SELECT THE SSEF PROGRAM

What describes best the item you are requesting payment for :

3 - DID YOU ALREADY PAY FOR THE ITEM OR EXPENSE ?

If you reply : - yes to this section please text a picture of your receipt - If we need to pay a provider please send a picture of an invoice 781 322 0063 or email SouthSudaneseBoston@gmail.com

Yes

4 - FILL THIS PART IF YOU HAVE DONE WORK FOR SSEF OR REQUEST EMERGENCY FUNDING:

Please enter the details of your work or expense for SSEF : - Number of hours worked and rate for example 4 h at $20/h. - Milage reimbursement (number of miles and destination).

5 - CHECK RECIPIENT INFORMATION (who will receive payment).

Name of the person or name of the business that needs to receive payment.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

6 - AMOUNT TO BE PAID?

Enter the total amount as it should appear on the check

7 - STAFF OR VOLUNTEERS ONLY:

If you did the request for a community member please enter your contact information below:

First Name

Last Name

Phone

(###)

###

####

Once this form is received, it will be reviewed. If there are questions, you will be contacted. Otherwise, your request will be processed for payment within two weeks.

If you have any questions, email or call:

SSEF Boston Email:
SouthSudaneseBoston@gmail.com

Phone Number:
781-322-0063

Payment Form

Complete and submit this form to request payment for expenses or services