Committee ______________________________________________
Event
______________________________________________
Remit Payment
to:
Name
___________________________________
Address ___________________________________
___________________________________
Telephone ___________________________________
Email:
___________________________________
Please note: Taxes are not refundable unless the store does not accept the BHPA tax identification
number. (All committee heads should have tax id forms available).
Description of
Attached Receipts:
Amount
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______________________________________________ __________
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Total Payment
Due
__________