Page One __________________________________Lodge No. ________

DATE OF THIS REPORT __________________________________, 20 _________

To the Grand Secretary The Grand Lodge of A. F. & A. M. of North Carolina 2921 Glenwood AvenueRaleigh, North Carolina 27608

REPORT OF DOINGS AT A STATED COMMUNICATION HELD ON

____________,20__This is to report the doings at our stated communication held on the date shown in the blocked caption

above, under the following subjects, as required by Regulation 59-12.19:

I: PETITIONS FOR DEGREES READ AND REFERRED TO COMMITTEES: (Originals herewith for your certificate.) (Be certain that you lodge has jurisdiction over each petitioner; that the name is legible, readable, is shown in FULL, and signed in FULL.)

1 ________________________________ 3 ________________________________ 5 ________________________________ 7 ________________________________

II: PETITIONERS FOR THE DEGREES ELECTED:

1 ________________________________ 3 ________________________________ 5 ________________________________

2 ________________________________ 4 ________________________________ 6 ________________________________ 8 ________________________________

III: DEGREES CONFERRED SINCE LAST REPORT, WITH DATES: Names

________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

First Degree ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____

Second Degree ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____ ________ 20 _____

Third Degree ________ 20 _____________ 20 _____________ 20 _____________ 20 _____________ 20 _____________ 20 _____________ 20 _____________ 20 _____________ 20 _____

IV: APPLICATIONS FOR AFFILIATION READ AND REFERRED TO COMMITTEES: (Originals herewith for your certificate.) (Be certain that CHAPTER 75 of THE CODE is fully complied with; and that each Application under Continuous Membership Plan has attached to it the required DUES RECEIPT and the REQUEST FOR THE DEMIT or the CERTIFICATE OF GOOD STANDING.)

1 _____________________________________________ 3 _____________________________________________

V: APPLICANTS FOR AFFILIATION ELECTED: 1 _____________________________________________ 3 _____________________________________________ 5 _____________________________________________

2 _____________________________________________ 4 _____________________________________________

VI: APPLICATIONS FOR RESTORATION READ AND REFERRED TO COMMITTEES: 1: ____________________________Date of Excl., Susp., or Exp________________________________________________20__. Address: __________________________________________________________________________________________________ VII: APPLICANTS RESTORED TO MEMBERSHIP, WITH DATES: 1: ____________________________________________Date Restored ____________________________________________20 __ Address: ___________________________________________________________________________________________________

(Continued on the back of this sheet) (Read instructions on the back of this

sheet)

2 ________________________________ 4 ________________________________ 6 ________________________________

2 _____________________________________________4 _____________________________________________ 6 _____________________________________________

NC Official Form 49

VIII: DIED (Since last report to Grand Secretary):

1 _____________________________________________ 2 _____________________________________________

Date of Death ________________________________________ Date of Death ________________________________________

IX: MEMBERS EXCLUDED FOR NONPAYMENT OF DUES:

1_____________________________________________ 3_____________________________________________ 5_____________________________________________ 7_____________________________________________ 9_____________________________________________ 11 _____________________________________________

2 _____________________________________________ 4 _____________________________________________ 6 _____________________________________________ 8 _____________________________________________ 10 _____________________________________________ 12 _____________________________________________

X: MEMBERS DEMITTED (If”dropped”—NCOF-ll-Regulation 75-15, give DATE): 1: ___________________________________________ 2._________________________________________________

XI: PETITIONERS FOR THE DEGREES REJECTED: 1: ___________________________________________

XII: APPLICANTS FOR AFFILIATION REJECTED: 1: ___________________________________________ 3: ___________________________________________

XIII: APPLICANTS FOR RESTORATION REJECTED: 1: ___________________________________________

XIV: PETITIONS WITHDRAWN: 1: ___________________________________________

2._________________________________________________

XV: COURTESY WORK FOR OTHER LODGES: (Since last report to Grand Secretary) Second Degree __________20 ___ __________20 ___

Names First Degree ___________________________________ __________20 ___ ___________________________________ __________20 ___ For________________________________ Lodge No. ______ For________________________________ Lodge No. ______

at __________________________________ at __________________________________

Note: (If there is not enough space under any foregoing subject, use the space below this line OR use another copy of this form properly dated and designated as No. 2. In either case, use the arrangement as set up under the appropriate subject. You may also use the space below for any COMMENTS, including information relative to HONORARY MEMBERSHIPS, which do not require a separate letter. Write SEPARATE LETTER on any and all subjects not covered in this report. Subject Number: Subject _______________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

Fraternally submitted, Secretary

_____________________________________ (SEAL OF LODGE HERE)

NOTES: 1. Report only those transactions which took place in the lodge at the stated communication shown in the blocked caption, except under the SUBJECT NUMBERS III, VII, VIII. 2. Lodges having concurrent jurisdiction may use copies of this form to give reports required under Regulation 59-12.16 of THE CODE. 3. Forms may be obtained from the Printing Department, The Masonic Home for Children, Oxford, N. C. 27565.

2._________________________________________________ 4._________________________________________________

2._________________________________________________

2._________________________________________________

Third Degree __________20 ___ __________20 ___