Relief Payment

The Lodge Relief Payment for Dues form is to be completed only by the Lodge Secretary, Treasurer, or Worshipful Master.
Each submission must be handled with accuracy, integrity, and full adherence to all current Grand Lodge Communications, Edicts, and established procedures.

Before completing this form, please ensure you:

• Have verified the member’s eligibility for Lodge Relief.
• Are authorized by your Lodge to submit the request.
• Have reviewed all applicable Grand Lodge directives regarding dues, remissions, and relief procedures.

If at any point you are uncertain about a requirement, instruction, or procedure, stop immediately and contact the Grand Lodge Office at 601‑354‑1403 for clarification.

Your diligence ensures that all relief requests are processed properly and in accordance with the laws and traditions of our Jurisdiction.

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Lodge Name and Number *

Name *

First

Last

Email *

Person Submitting Payments *

• Worship Master
• Secretary
• Treasure
• Other

Name 1

First

Last

Enter the Brother Name

Masonic Member ID Number

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment Type 1

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Select type of membership.

Name 2

First

Last

Masonic Member ID Number 2

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment Type 2

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 3

First

Last

Masonic Member ID Number 3

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment 3

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 4

First

Last

Masonic Member ID Number 4

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment Type 4

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 5

First

Last

Masonic Member ID Number 5

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment Type 5

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 6

First

Last

Masonic Member ID Number 6

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment Type 6

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

17 Name ID

Name 7

First

Last

Masonic Member ID Number 7

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment Type 7

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 8

First

Last

Masonic Member ID Number 8

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment Type 8

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 9

First

Last

Masonic Member ID Number 9

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment 9

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 10

First

Last

Masonic Member ID Number 10

Enter the current Membership ID number for the Brother. If member is reinstating and number is unknown type (Unknown) If new type new member in this box.

Payment Type 10

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 11

First

Last

Membership ID 11

Payment Type 11

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 12

First

Last

Membership ID 12

Payment Type 12

• Current Memeber – $55.00
• New Memeber – $5,800.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 13 *

First

Last

Membership ID 13

Payment Type 13

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 14 *

First

Last

Membership ID 14

Payment Type 14

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 15 *

First

Last

Membership ID 15

Payment Type 15

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 16 *

First

Last

Membership ID 16

Payment Type 16

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 17

First

Last

Membership ID 17

Payment Type 17

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 18

First

Last

Membership ID 18

Payment Type 18

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 19

First

Last

Membership ID 19

Payment Type 19

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 20

First

Last

Membership ID 20

Payment Type 20

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 21

First

Last

Membership ID 21

Payment Type 21

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 22

First

Last

Membership ID 22

Payment Type 22

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 22

First

Last

Membership ID 22

Payment Type 22

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 23

First

Last

Membership ID 23

Payment Type 23

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 24

First

Last

Membership ID 24

Payment Type 24

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 25

First

Last

Membership ID 25

Payment Type 25

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Name 26

First

Last

Membership ID 26

Payment Type 26

• Current Memeber – $55.00
• New Memeber – $58.00
• Reinstatement – $110.00
• Reinstatement (5 or More) – $65.00

Enter Relief Payment Below

Type in Brothers Name and Number then select Payment Type.

Note to the Grand Lodge

Total

$0.00

Submit