The Most Worshipful Prince Hall Grand Lodge, F. & A.M.

WASHINGTON and JURISDICTION

_____ QUARTERLY REPORT AND TAXES OF

NAME OF LODGE: ______

LOCATED AT:______MEETS ON: ______

REPORTING PERIOD FROM: ______, 2001 To ______, 2001

PAYMENTS TO GRAND LODGE
See 2nd Page
**Per Capita Tax:……………………($ 8.80)
Totals: /
MEMBERSHIP
Active Members:
Active Members: / @ / $ 8.80 / $ / Indigent & Lodge Honorary:
Indigent & Lodge Honorary: / @ / $ 1.15 / $ / Grand Lodge Honorary:
Initiations: / @ / $ 10.00 / $ / TOTAL MEMBERS: / 0
Dispensations: / @ / $ 3.00 / $ /
LODGE
WORK AND ACTIONS
Prince Hall Day: 100 @ $1.00 / $
Assessments: / $ / Initiated:
KOPEI: / $ / No. Degrees Given:
Merchandise: / $ / Dropped for N.P.D.:
Grand Lodge Building Assessment: / $ / Reinstated:
Miscellaneous: / $ / Received by Demit:
Adjustments: / $ / Demitted:
Over Payments (Subtract) 4th Qtr Tax Report Overpayment / $ / Suspended:
Short on Last Report (Add)…………………………………….. / $ / Expelled:
TOTAL AMOUNT PAID: / 0 / Deaths:

Note: Secretaries, please prepare and fill in ACCURATELY…forward to the Grand Secretary’s Office, and retain a copy for your own files.

(______)Total Membership Ending (End of last Qtr Date) ______(______) INCREASE (______) DECREASE

(______) Total Membership Ending (End of this Qtr Date) ______(______) INCREASE (______) DECREASE

______

PRINT SIGNATUREW.M.

______

PRINT ADDRESS

______

PRINT SECRETARY

______

AFFIX PRINT ADDRESS

YOUR LODGE’S

SEAL HERE

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LODGE WORK AND ACTIONS

INITIATED / DEGREES /
DROPPED FOR NON-PAYMENT OF DUES
DATE NAME (Print)
/
1
/
2
/
3
/ DATE / NAME (Print)
REINSTATED

DATE

/ NAME (Print)
RECEIVED BY DEMIT
DATE / NAME (Print)
DEMITTED
DATE / NAME (Print)
EXPELLED
DATE / NAME (Print)
DEATHS
DATE / NAME (Print)

QUARTERLY REPORT FOR _____ QUARTER

Do Not Write these Spaces
(For Grand Secretary’s Use Only)
Over Under
Grand Tax / @
Masonic Relief: / @
Charity: / @
Education: / @
Youth: / @
Building Fund: / @
Investments: / @
**Per Capita Tax: Includes Grand Lodge Tax
Masonic Relief:
Charity:
Education:
Youth:
Building:
Investment:
TOTAL PER QUARTER:

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