PAYMENT FORM

Local's Name *
Local's Name
Program Local Participates In *
Name of staff member entering this payment information *
Name of staff member entering this payment information
Date Payment Received *
Date Payment Received
$
Payment Type *
If partial payment received, scheduled date for remaining balance to be received
If partial payment received, scheduled date for remaining balance to be received
$
Method of Payment *
If cash, enter "cash"