Trade Mark		Reg. U.S. Pat Off.:
MEMBER’S PHILANTHROPIC REPORT
	     	
Date
	     		     	
Member’s Name	Court
The following is an accurate and true account of the philanthropic work performed by myself during the calendar year from January 1 to December 31,	    	, or the value of items or monies donated to charitable causes.
1.	Hours of volunteer work performed at Homes or Hospitals 	     	
Other volunteer work performed with 	     	.
2.	Funds donated to local educational institutions  $ 	     	
Name of school  	     	.
Monies donated to Grand Court educational funds $ 	     	
3.	Value of items (clothes, food, furniture) donated to local charities $ 	     	
These items were donated to 		,		     	,
and 	     	.
4.	Total of monies donated to local charities  $ 	     	.
These monies were donated to 	     	,		     	
and 	     	.
5.	Relief given to worthy members $      	.	  Name of member to whom relief was given is 	     	.
6.	Other charitable work performed or funds given to:
	     			     	
(Organization)	(Amount)

(Signature)
Note:  This report must be submitted to the Court Secretary annually by the date required in your Grand Court By-laws.