Please mail the original of this form together with the original of the Fair Share Contribution Form and a check in full or partial payment of your Fraternity’s fair share contribution to the Regional Treasurer (see Directory for name and address).  Additionally, please include these forms with your Annual Report to the Regional Minister (see Directory for name and e-mail address).  Thank you.

REPORT FROM JANUARY 1, THROUGH DECEMBER 31, 20_____ 

FRATERNITY NAME:
CITY, STATE and ZIP CODE:	                                                                                                                                              

INCOME:		
		
Fair Share Contributions	$                                       	
Interest Income	                                          	
Formation Sales	                                           	
Retreat Fees	                                          	
Social Gathering Events	                                          	
Miscellaneous		
		
     TOTAL INCOME	$	
		
EXPENSES:		
		
Regional Fair Share	$                                        	
Formation Materials and Supplies	                                          	
Stipends	                                          	
Retreat Expenses	                                          	
Meeting Facility Costs	                                          	
Newsletter 	                                          	
Travel and Costs Reimbursements	                                          	
Miscellaneous	                                          	
Contributions	                                          	
Special Event Costs	                                          	
		
     TOTAL EXPENSES	$	
		
     NET INCOME (EXPENSE) 	$