A L P H A P H I A L P H A F R AT E R N I T Y , I N C .
®
| PO BOX 405478, ATLANTA, GA 30384-5478
Remittance of Funds Report – Taxes & Fees
FOR OFFICE USE ONLY
Remitter Information
TRANSACTION DATE: ______________
Chapter
PROCESSED BY:
Key # Total Amount Remitted: $ Account#
______________
DATE PROCESSED:
______________
REMITTANCE NO:
______________
Grand Tax
Late Fee
NHBF
(REQUIRED)
PLEASE PRINT OR TYPE (In alphabetical order)
Name
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
$10
$100
$10
$100
$10
$100
$10
$100
$10
$100
st
nd
City
State
Zip
1 and 2 year alumni fees apply only to college members coming directly out of college. st
Name
nd
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
1 and 2 year alumni fees apply only to college members coming directly out of college. st
Name
nd
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
1st and 2nd year alumni fees apply only to college members coming directly out of college.
Name
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
1st and 2nd year alumni fees apply only to college members coming directly out of college.
Name
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
CHAPTER TAX FEES:
State
Zip
1st and 2nd year alumni fees apply only to college members coming directly out of college.
Past Due
Current
CHAPTER INSURANCE FEE LATE FEE
$700
$50
PAST DUE FEES ARE FEES THAT HAVE NOT BEEN PAID FROM A PAST FRATERNAL YEAR.
SENDER INFORMATION:
Name/Chapter
Title
Address City
State
Zip
DID YOU FOLLOW THE INSTRUCTIONS ON THE LAST PAGE!!
Phone: Email: Phone: 1.800.3733089 | Fax: 301.206.9789 Email: forms@apa1906.net
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A L P H A P H I A L P H A F R AT E R N I T Y , I N C .
®
| PO BOX 405478, ATLANTA, GA 30384-5478
Remittance of Funds Report – Taxes & Fees
Remittance of Funds Report Cont.
PAGE NUMBER
Account#
PLEASE PRINT OR TYPE (In Alphabetical Order)
Remittance No.
Grand Tax
Late Fee
NHBF
(REQUIRED)
Name
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
$10
$100
$10
$100
$10
$100
$10
$100
$10
$100
$10
$100
$10
$100
$10
$100
st
nd
City
State
Zip
1 and 2 year alumni fees apply only to college members coming directly out of college. st
Name
nd
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
1st and 2nd year alumni fees apply only to college members coming directly out of college.
Name
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
1st and 2nd year alumni fees apply only to college members coming directly out of college.
Name
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
1st and 2nd year alumni fees apply only to college members coming directly out of college.
Name
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
1 and 2 year alumni fees apply only to college members coming directly out of college. st
Name
nd
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
1 and 2 year alumni fees apply only to college members coming directly out of college. st
Name
nd
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
Name
1 and 2 year alumni fees apply only to college members coming directly out of college. st
nd
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
Address
st
nd
City
State
Zip
Phone: 1.800.3733089 | Fax: 301.206.9789 Email: forms@apa1906.net
1st and 2nd year alumni fees apply only to college members coming directly out of college.
Page 2 of 3 tmpNVsgqK updated 08/12/2009
A L P H A P H I A L P H A F R AT E R N I T Y , I N C .
®
| PO BOX 405478, ATLANTA, GA 30384-5478
Remittance of Funds Report – Taxes & Fees
REMITTANCE OF FUNDS REPORT INSTRUCTIONS 1. Only include names of grand tax payers and/or members/life members paying the NHBF for the first time. (This is not a chapter roster submission form) 2. List full name, account number, and mailing address of each person listed. 3. Use social security number if account number is unavailable. 4. A fully completed member profile form should be submitted with this form for any name submitted on this form that has been inactive for 2+ years. 5. The $100 NHBF payment should be submitted for all members initiated prior to 1986 that have not previously paid it. 6. Check the box next to the address line if there has been a change of address. 7. All late fees (grand tax and chapter tax) are applied after November 15. 8. Please keep copy for chapter records and receipts will be sent upon request only. 9. There is a $35 NSF Fee for all returned payments from our financial institution. 10. All payments should be made payment to Alpha Phi Alpha Fraternity, Inc. 11. Payments should be forwarded to the following address: Alpha Phi Alpha Fraternity, Inc. P.O. Box 405478 Atlanta, GA 30384 - 5478 12. Please allow 10-12 business days to be processed in the membership database after mailing it to the PO Box. 13. Payments forwarded to the Corporate Headquarters will take longer to process because it will have to be forwarded to the bank by someone on the staff. 14.
DO NOT RETURN THIS PAGE WITH YOUR REMITTANCE!
Phone: 1.800.3733089 | Fax: 301.206.9789 Email: forms@apa1906.net
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