Application For Relief From Payment Of Council Dues And Supreme And State Council Per Capita Taxes - The Knights Of Columbus

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APPLICATION FOR RELIEF FROM PAYMENT
OF COUNCIL DUES AND SUPREME AND
STATE COUNCIL PER CAPITA TAXES
I hereby certify that I, ____________________________________, _______________________
Name
Address
____________________________, am a member in good standing of Council No. _________
and that I am totally disabled and hereby request that I be relieved of payment of all
council dues and Supreme and state council per capita taxes under Section 118(e) of
the Laws of the Order. In support of this request, I submit one of the following as
evidence of my total disability:
(
) Certification from Health and Human Services, or
(
) Certification from Internal Revenue Service, or
(
) Certification from Veterans’ Administration, or
(
) Certification from attending physician.
_________________________
_______________________________________
Dated
Member Signature
CERTIFICATION OF COUNCIL
__________________
Council No.
____________________________________
Location
This is to certify that ________________________________________________, _______
_____,
_____
Name
Membership Number
is a member in good standing in this council and that he has presented evidence of total
disability that warrants consideration for relief from payment of all council dues and
Supreme and state council per capita taxes, under Section 118(e).
_______________________________
________________________________________
Attest:
Financial Secretary
Grand Knight
_____________________________
Dated
(affix council seal here)
INSTRUCTIONS TO FINANCIAL SECRETARY: Forward completed form with applicant
and officer signatures and accompanying proof of disability to: Knights of Columbus,
Department of Membership Records, 1 Columbus Plaza, New Haven CT 06510-3326.
NOTICE: Approval of this application for dues consideration does not have any effect on the waiver of insurance
contributions on an insurance certificate held by the member.
1831
1-01

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