Ia Form 28a-Grand Knight Is Responsible For All Funds And Filing Report-Council Report Form 2013

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Report is late after Dec 31
(Please type or print clearly)
IA Form 28A
IOWA KNIGHTS OF COLUMBUS
CAMPAIGN for
PERSONS with INTELLECTUAL DISABILITIES (CPID)
COUNCIL REPORT FORM
GRAND KNIGHT IS RESPONSIBLE FOR ALL FUNDS AND FILING REPORT
Date of report filing: ____________
Council No. ____________ Council’s District No. _________ Council City: ________________________
Grand Knight: _________________________________________ Telephone: ______________________
Address: __________________________________________________________________________
City: ____________________________ State: _________________ Zip: ________________________
Send TOTAL amount collected (Step 1 below) by check payable to:
“Iowa Knights of Columbus CPID Fund”
along with a copy of this report to:
Iowa Knights of Columbus, 2200 NW 159th St., Suite 400, PMB 275, Clive, IA. 50325
Step 1 Enter total amount collected and/or donated by council:
$ _____________
Step 2 No. of cases of Tootsie Rolls your council ordered _______ X $19.50 = $ _____________
Note: If no Tootsie Rolls were used, enter “0”
Step 3 Subtract Step 2 amount from Step 1 amount and enter that here:
$ _____________
Step 4 Multiply Step 3 amount by 10% (0.10) and enter that total here:
$ _____________
This amount is used for Special Olympics & other state wide projects.
Step 5 Subtract Step 4 amount from Step 3 amount and enter that here:
$ _____________
This is the amount returned to the local council for distribution.
Step 6 List total man hours council expended on the CPID drive effort here:
_____________
List below the charity/charities and the amount you wish them to receive. Funds will be processed and
returned to the Grand Knight’s address above. Send a copy of this CPID report to your District Deputy and
keep a copy for your council’s record.
~~~~~~~~~~~~~~~~~~~~Distribution to Charities as follows:~~~~~~~~~~~~~~~~~~~~~~
1.
______________________________________________________
$ ___________
2.
______________________________________________________
$ ___________
3.
______________________________________________________
$ ___________
4.
______________________________________________________
$ ___________
5.
______________________________________________________
$ ___________
6.
______________________________________________________
$ ___________
7.
______________________________________________________
$ ___________
8.
______________________________________________________
$ ___________
Total Distribution (Must equal Step 5 above)
$ ___________
Report Filing Deadline is December 31
Form updated 2-12-2013

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