CASH RECIEPT TRANSMITTAL FORM

							                         CASH RECIEPT TRANSMITTAL FORM

PLEASE COMPLETE THIS FORM AND RETURN TO THE IMA IN A SEALED ENVELOPE WITH ALL CASH, CHECKS AND
CHARGES TO THE ATTENTION OF REBEKAH BADGLEY, FINANCIAL ANALYST.


                        Date:
             Affiliate Group:   Choose item
             Program/Event:


                                Affiliate Count                      Finance Office Only

 100's                                     $           .00
 50's                                      $           .00
 20’s                                      $           .00
 10's                                      $           .00
 5's                                       $           .00
 2's                                       $           .00
 1's                                       $           .00
 Coin                                      $           .
 Checks                                    $           .
 Charges                                   $           .
 Subtotal                                  $           .
 Less Start Up                             $           .
 Net Total                                 $           .
 Total Amount to be
 Credited                                  $           .

                                      Account No.      Choose item

                                         Signature



 Finance Office Only - Verification of Cash Receipts

 Date                                                  Dept.
                                                       A/C
 Program/Event                                         No.

                                Amount Per Transmittal
                                Amount
                                Deposited
                                Variance (If Any)