Widows Program Reimbursement
Lodge Name
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Lodge #
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SECY Name
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SECY Address
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SECY City
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SECY State
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SECY Zipcode
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Contact #
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Brief Description of Widow Program/Activity
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How many widows present
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Do any widows need follow-up or assistance?
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Name of widow needing Assistance
Contact Information of Widow needing Assistance
Total Cost
*
Receipts
*
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Date Submitted
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