September 1, 20___ to August 31, 20___
Number of Members reported last August 31st 
Number Greeted (received Super-Excellent Degree)  
Number Reinstated during year  
Number Affiliated during year  
*Plus Adjustments  
Sub-Total Increases  
Number Demitted during year  
Number Suspended during year  
Number Expelled during year  
Number Deceased during year  
*Minus Adjustments  
Total Deductions  
Total Membership on August 31, 20_____  

Fee for the Degrees: $_________ Annual Dues $____________
Excluding Grand Council Dues

Annual Fee $25.00
___ Candidates (Royal Master Degree only) at $5.00 each $____.00
___ Members at $ 9.00 each $____.00
Includes $8.00 Grand Council Dues
and $1.00 Medical Research Foundation
TOTAL FEE $____.00
LESS:Claimed on G.C.D. Form, see attached form$____.00 
........Mid-Year Payment$____.00 
........Total Deduction (credit)$____.00 
TOTAL Amount Due Grand Council October 1st $____.00
ATTEST: Recorder

$__________ _____________________ A.D. 20___ Check #__________________
Received the amount due the Grand Council agreeably to the foregoing returns. ___________________________________________ Grand Recorder