Fillable FOOD FOR FAMILIES REIMBURSEMENT PROGRAM REFUND AND PLAQUE (Knights of Columbus Chicago District 18 )

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FOOD FOR FAMILIES REIMBURSEMENT PROGRAM REFUND AND PLAQUE (Knights of Columbus Chicago District 18 )

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For Office Use Only
Ref $ _____________________________
Y. St. _____________________________
Date ______________________________
SECTION I AND II MUST BE COMPLETED TO BE ELIGIBLE FOR THE FOOD FOR FAMILIES PLAQUE
......................................................................................................................................................................................................................
SECTION I: REFUND INFORMATION
See directives on the reverse side before completing this section.
List each contribution of $500 or more with name, amount and date of check, or each contribution of 500 or more pounds of food.
Attach copies of canceled checks (both front and back sides) or other documentation to this application.
Important: Please complete this box:
State/Province ____________________ Council No. __________________
Location ________________________________________________________
city
Council Name ___________________________________________________
Grand Knight ____________________________________________________
Due By: JUNE 30
REFUND AND PLAQUE APPLICATION 20__-20__
FOOD FOR FAMILIES REIMBURSEMENT PROGRAM
NAME OF FOOD BANK ADDRESS CITY / STATE ZIP DATE CHECK # AMOUNT POUNDS OF FOOD
......................................................................................................................................................................................................................
SECTION II: MANPOWER SUPPORT INFORMATION
See directives on the reverse side before completing this section.
Please provide a summary of manpower support provided to food banks and/or food pantries, including hours of
service contributed, in order to receive a Food for Families plaque or date plate.
Hours of Service Provided ___________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
IMPORTANT: Be sure to check off one of the following:
We already have a Food for Families Plaque and require only an adhesive date plate for 20__-20__.
This is our first year participating in Food for Families and we require both a plaque and an adhesive date plate
for 20__-20__.
Our Food for Families Plaque is full and we require a new one.
I AFFIRM THE ABOVE TO BE ACCURATE: ___________________________________________________________________
Grand Knight Food Bank Representative
Date: _________________________________________
MAIL ORIGINAL TO: Supreme Council Department of Fraternal Services
MAIL COPIES TO: State Program Director, Council File
(See other side for instructions)
10057 11/12
FOOD FOR FAMILIES REIMBURSEMENT PROGRAM
10057 11/12
Due By: JUNE 30
The Knights of Columbus Food for Families Reimbursement Program was established in 2012. Under this program,
local Knights of Columbus councils or assemblies make an annual contribution of $500 or more, or 500 pounds of food
to a local community food bank or parish food pantry. For every $500 or 500 pounds of food contributed, the council
or assembly is eligible for a refund of $100 from the Supreme Council. The maximum refund a council or assembly can
receive is $500 per fraternal year. For Columbian Squires circles, the minimum donation is $100, or 100 pounds of food,
with each circle eligible to receive from the Supreme Council a refund of $20 for each $100 donated or 100 pounds of
food. Reimbursement must be applied for in the fraternal year during which contributions were made.
As resources permit, councils, assemblies and circles may provide support to multiple food banks and/or food
pantries. The minimum contribution to qualify for a refund is $500 ($100 for Squires circles) for each food bank/food
pantry supported.
In addition to a refund for financial contributions, councils, assemblies and circles are also eligible to receive a Food
for Families plaque (and, in successive years, date plates signifying years of participation) in recognition of manpower
support provided to food banks and food pantries. Significant manpower support is required, and should be outlined
in Section II of this application.
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FOOD FOR FAMILIES REIMBURSEMENT PROGRAM REFUND AND PLAQUE (Knights of Columbus Chicago District 18 )

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Completed 14 August 2021

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