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
Page 1 of 3 tmpNVsgqK updated 08/12/2009