Form 51 - Remission of Dues

First Name *

Middle Name

Last Name *

Suffix

Membership Number *

Please include the M at the beginning

Lodge Name *

Lodge Number *

Secretary Name *

Secretary Email *

Lodge Remarks *

You must enter the reason for the remit that was voted on.

Dues Remission for Year: *

2025

*Remits can only be submitted from January thru October 20th of the remission year anything outside this time frame will be denied.

Date Approved By Lodge *

Live Better at Home Member Care Services will call this member to let them know we are here and what services are available. *