U.S.

AFRICAN DEVELOPMENT FOUNDATION

Disbursement Request Form
(Complete both pages)

GENERAL INFORMATION
Page 1 of 2
Project Name: PROJET DE RENFORCEMENT DES CAPACITES ADMINISTRATIVES
Grant No: ET DE PRODUCTION
Date Prepared: Currency:
Period Covered- From: To:

FUNDS REQUESTED
Line
Item Line Item Name Amount

A.1
B.1
C.1
D.1
E.1
F.1

Total Amount Requested

Submitted by:

Signature Name

Title

Updated 11-12-15
 U.S. AFRICAN DEVELOPMENT FOUNDATION
Disbursement Request

DISBURSEMENT INSTRUCTIONS & CERTIFICATION

(send funds to:)

Bank Name: ECOBANK GRAND BASSAM

Project Account Name:

Project Bank Account Number:

(record the last four characters of account number only)

Bank Address:

Bank Fax Number:

Name of Contact Person at Bank:

THIRD PARTY DISBURSEMENTS

IF YOU ARE REQUESTING THAT THIS DISBURSEMENT BE MADE

DIRECTLY TO A VENDOR, THE FOLLOWING MUST BE COMPLETED

I authorize that the funds herein requested to be paid by USADF on behalf of

(Name of Grantee)

out of available grant funds to the vendor shown above.

This payment is for items or services we have ordered from this vendor for use in carrying out the project
described in our grant agreement with USADF. If the payment is to be made in a currency other
than the currency in which the grant agreement is denominated, I agree that USADF may charge
the grant at the exchange rate prevailing on the last day of the month in which the disbursement
is made, as determined by USADF. For a single purchase of $5,000 or more I certify that the procurement
process was valid and true, and that there is no conflict of interest with any of the parties involved.

Signature Name

Title

Note: Include any information needed by USADF about your request

Updated 11-12-15