Date:   Date   Location: Meeting Location

Name of Church Church Name Address:  Church Address              
Diocesan BishopDiocesan Bishop    Diocesan Superintendant    Superintendant    
Pastor:   Pastor Name           Local Superintendant: Local Superintendant
Address:Superintendant Address Sup. Phone:      Superintendent Phone                     
Local Secretary   Local Secretary   Secr. Phone   :   Secretary Phone              

Number of Scholars:   No. of Scholars       Teachers & Officers:   Teachers& Officers   
Number of Classes:   No. of Classes  Number of Active Members:   Active Members   
Number of Inactive Members:   Inactive Members   

Average Attendance Last Semi-annual:   Avg Last Semi   
Average Attendance This Semi-annual:   Avg This Semi   

Number of Sunday school Scholars baptized:   No. Baptized   
Number of Sunday school Receiving the Holy Ghost:     No. Spirit Filled       

Amount of Offering Last Semi-annual:   Offering Last Semi   

This Semi-Annual:   Offering This Semi   

Representation Fee ($5.00)   Representation Fee         

Teacher & Officer Representation   Teacher & Officer Fee   

Per Scholar Representation ($.25)   Per Scholar Fee   

Total Paid to National Body (10%) Thru Diocese   Total 10% Diocese   

Total Paid to National Body (10%) Directly   Total 10% Direct   

Diocese Superintendent Love Offering ($15.00)   Sup Love Offering   

Diocese Secretary Love Offering ($5.00)   Secretary Offering   

Scholarship Book Fund Offering   Scholarship Offering   

Director's Love Offering ($10.00)   Director Offering   

Home Mission Offering ($10.00)   Home Mission Offering   

Total Amount Submitted with This Report   Total Submitted