MOST WORSHIPFUL PRINCE HALL GRAND LODGE ・ FREE AND ACCEPTED MASONS ・ STATE OF CALIFORNIA INCORPORATED Waiver Facility of Payment Applicant under the age of 60 I ____________________________ of my own free will and understanding do hereby waive all rights and benefits to Masonic Relief during the first five years of my membership in the Lodge as Designated by (Article V, Page 306, Section 2 of the Masonic Constitution, Most Worshipful Prince Hall Grand Lodge, F. & A. M., State of California, Inc.) under the Heading “Full Benefits for all”. Further should my death occur within the first five years of my entry upon the Lodge’s rolls as a Master Mason, in which case I hold, neither the Grand Lodge nor any Subordinate Lodge responsible for any indebtedness incurred by any person or persons responsible for my burial, and do hereby proclaim that all disbursements coming from the Lodge or Grand Lodge shall be waived. I further agree and understand that upon or thereafter, the Fifth (5th) anniversary of my entry into the Lodge, and my membership being constant and continuing as a dues paying member therein, any person or persons incurring expense on behalf of my burial, upon filing a proper claim will be reimbursed in the amount not to exceed four hundred ($400.00) dollars toward my burial expenses. _________________________ Applicant __________________________________________________________________ For Lodge Use _______________________ Lodge No. F. & A. M. Applicant entered on Lodge Rolls (Master Mason) _______________________ 20 ___ Witness: ______________________________ W. M. (Lodge Seal) ___________________Secretary Note: Complete four copies: Grand Master, Grand Secretary, Applicant, Lodge Files