A L P H A P H I A L P H A F R A T 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: $
DATE PROCESSED:
______________
REMITTANCE NO:
______________
Grand Tax
Late Fee
NHBF
$ 150 Alumni $ 75 College $ 75 1 Year Alumni $ 112.50 2 Year Alumni
$10
$100
$10
$100
$10
$100
$10
$100
$10
$100
Account# (REQUIRED)
PLEASE PRINT OR TYPE (In alphabetical order)
Name 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
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
Past Due
CHAPTER TAX FEES: Current YEAR.
1st and 2nd year alumni fees apply only to college members coming directly out of college.
LATE FEE
$50
CHAPTER INSURANCE FEE
$700
PAST DUE FEES ARE FEES THAT HAVE NOT BEEN PAID FROM A PAST FRATERNAL
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 original.doc updated 08/12/2009