Facilitation Payment Disclosure Form
Please complete this form to disclose any facilitation payments made for routine government actions. Accurate and complete information is required for compliance and transparency.
Full Name of Person Making Disclosure
*
First Name
Last Name
Email Address
*
example@example.com
Department or Business Unit
*
Date of Disclosure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Facilitation Payment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facilitation Payment Amount
*
Currency
*
Please Select
USD
EUR
GBP
Local Currency
Recipient of Payment (Name of Individual or Organization)
*
Purpose of Facilitation Payment
*
Payment Method
*
Cash
Bank Transfer
Check
Other
Supporting Documentation (e.g., receipt, proof of payment)
Upload a File
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of
Signature
*
Submit Disclosure
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