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Sedona, Ltd. Request Form

Date

Month

Day

Year

Name of Client

Service/ Bill Requested to be Paid

Organization Representative Requesting Funds

Reason for Request

Amount Requested

I attest that the above client is truly indigent and in need of emergency funds and other funding resources are unavailable.

Signature of Initiating Request

Signature of Supervisor

File upload

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Sedona, Ltd. is a nonprofit, tax-exempt charitable organization #EIN 87-3802109 under Section 501(c)3 of the Internal Revenue Code. Donations are tax-deductible as allowed by law.

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