APPLICATION FOR GRAND LODGE KATRINA RELIEF FUNDS BY INDIVIDUAL MASONS, MASONIC WIDOWS OR ORPHANS

Print individual's name

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Address

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Lodge &

Location______________________________________________________________

Amount of damage or out-of-pocket expense not covered by insurance or

contributions $_______________

Amount of relief funds already received from Grand Lodge Relief

$_______________

State purposes for assistance:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

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On my honor as a Mason (or Masonic widow/orphan), I declare the above

statements to be true.

Submitted by:

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(Signature)

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Worshipful Master

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Secretary

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FOR GRAND LODGE USE ONLY

Amount awarded: $_____________________

Approved by: _______________________________

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