Membership Report and Per Capita Tax Payment

Membership Report and Per Capita Tax Payment

First half tax due NOVEMBER 1st - Last half tax due MAY 1st, Each Year
Date*

MonthDayYear
Date
For the Year Of*
Lodge Name*
Lodge #*
Total Number of Members on National Membership Roster*
Total Loss of Membership
New Members
Transfers In
Reinstated
Total Gain of Membership
TOTAL NUMBER OF MEMBERS PER CAPITA TAX IS DUE ON
STATE LODGE PER CAPITA TAX
First Half Year: $ 10.00 Per Member

Full Year: $ 20.00 Per Member
Total*
NATIONAL FOP PER CAPITA TAX
First Half Year: $ 5.75 Per Member

Full Year: $ 11.50 Per Member

Administrative Fee @ $ 25.00
Total*
Balance

(From National FOP Membership Report)
Total*
How will you be making payment?*

Electronic Payment Through ACH (Current ACH Authorization MUST be on file.)I Will Mail a Check
If I choose to make payment electronically through ACH, I hereby authorize the Wisconsin State Lodge, Fraternal Order of Police, to initiate an ACH debit from the bank account on file for the payment of State and National per capita and associated fees for the amounts indicated above.
Local Lodge Secretary*

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