Application for Per Capita Disability Exemption

Application FOR RELIEF FROM PAYMENTOF COUNCIL DUES AND SUPREME ANDSTATE COUNCIL PER Capita TAXESI hereby certify that I,_____, _____Name Address_____, am a member in good standing of Council that I am totally disabled and hereby request that I be relieved of payment of allcouncil dues and Supreme and state council per Capita taxes under Section 118(e) ofthe Laws of the Order. In support of this request, I submit one of the following asevidence 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 _____Member SignatureCERTIFICATION OF COUNCILC ouncil is to certify that _____,_____,NameMembership Numberis a member in good standing in this council and that he has presented evidence of totaldisability that warrants consideration for relief from payment of all council dues andSupreme and state council per Capita taxes, under Section 118(e).

Application for Per Capita Disability Exemption 1831 3/22 CERTIFICATION OF COUNCIL Council No. _____ This is to certify that _____, _____, is a

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