Dues Remittance Form

Omega Psi Phi Fraternity, Inc.

Upsilon Omega ChapterDues & Assessments Remittance Form
Please fill out this form if you are paying any annual dues or assessments.

Last Name

First Name

Middle Name

Suffix (Jr/III,etc)

Address:

City:

State:

Zipcode:

Home Phone:

Work Phone

Cell Phone

Your E-mail address:

Date of Birth

Chapter in which initiated:

Date or Year Initiated:

Control Number (if known):

Did you pay your international, district, chapter and housing dues and assessments in full during the previous fiscal year?

Yes

Spouses Name:

Spouse's E-mail address:

Do we have your consent to forward this information to the Quettes?

Yes

The following dues and assessments are payable to or through the Upsilon Omega Chapter c/o the Keeper of Records and Seal. Check each box that applies:

Annual International Dues (Waived for life members) $100.00

Annual District Dues $35.00

Annual Chapter Dues $50.00

Late Fee (if paid after December 31st) $5.00

Reinstatement Fee if you were not financial last year $3.00

Lifetime International Headquarters Assessment(if not previously paid) $200.00

Life Membership Fee $2,000.00

Life Membership Fee (1st Installment) $1,000.00

Life Membership Fee (2nd Installment) $1,000.00

Total International, District & Chapter dues paid to Chapter KRS

The following dues and assessments are payable to or through the Upsilon Omega Foundation, are fully tax deductible, and mandatory as a Chapter assessment, c/o the Treasurer. Check each box that applies:

Annual Omega Center-Upsilon Omega Foundation Charitable Contribution (mandatory) $480.00

Annual Omega House-Upsilon Omega Foundation Charitable Contribution (mandatory - will be combined with Omega Center payment after house sold) $120.00

Combined Annual Omega Center-Omega House Charitable Contribution ($480+$120 combined) $600.00

Lifetime Omega Center Assessment (if not previosly paid) $200.00

Total contributions to Foundation paid through Foundation Treasurer

Combined total remitted to Chapter KRS & Foundation Treasurer

Please identify any committees, offices or programs that you want to be placed into or manage. Please make any brief comments, suggestions or questions here:

Please provide the name, address, phone number and e-mail address of any inactive brothers that we can attempt to reclaim:

Note: You may either pay your dues by mail or charge it to your credit card online through "pay pal" a secured online payment service with a small handling charge to you. You may also charge your dues and assessments to your credit card or provide for debit against your bank accoount by submitting this form directly to the KRS at any Chapter meeting and signing the authorization to charge it to your credit or debit card or provide for monthly debits against your bank account. If you pay by mail you must print this form and mail your payment to the Omega Center, 3900 Goodfellow Blvd., St. Louis, MO 63120.

You will be directed to our online payment page after clicking the submit button.

Regardless of the method of payment, you should print this form before clicking the submit button.

Upsilon Omega Home Page: angelfire.com/mo/upsilonomegapsiphi

You may access this Dues Remittance Form at: http://www.formsite.com/upsilonomega/duesremit/index.html

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