Dues Statement

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					                                                                  CHECK MADE PAYABLE TO: Hillsborough County Medical Association
                2012                                              CREDIT CARD PAYMENT: Master Card                 Visa          AmEX
                                                                   (circle one)
    DUES STATEMENT                                                                      PLEASE COMPLETE & SIGN

                                                                 Card # ___________________________________ Exp. Date _____________
   Hillsborough County Medical Assn.
   606 S. Boulevard                                              Three or four digit pin # on back of credit card _____________
   Tampa, FL 33606                                               Authorized Signature _______________________________________________
   813/253-0471
                                                                 Billing address of credit card:_________________________________________

                                                                 ________________________________________Zip: ____________________

                                                                 Daytime phone: ( _______) __________ - _____________
   Name: ______________________________
                                                                 Payment total: $______________________
   Phoned in by: _______________________
                                                                 PAYMENT IS FOR:           HCMA         HILLPAC          FOUNDATION 

                                                                 *See below for a convenient way to pay your dues*
   Date: ______________

Association dues are due and payable January 1. Dues are delinquent after February 1 and members are dropped for non-payment after April 30.




                                                                                                                            Amount Due
      HILLSBOROUGH COUNTY MEDICAL ASSOCIATION
      Annual Dues                                                                                                       $____________
      Membership Category: __________________

                               Optional/Additional:

           HILLPAC- Hillsborough Political Action Committee                                                                         50.00

           HCMA Foundation*                                                                                                        100.00

   TO ENSURE PROPER POSTING, PLEASE ENCLOSE A COPY                                                    TOTAL
   OF THIS STATEMENT WITH YOUR PAYMENT                                                             REMITTED: $ ____________

   *Your contribution may be tax deductible.




 HCMA Members are offered the option of automatic renewal. By signing below you will authorize the
 Hillsborough County Medical Association to automatically charge the above credit card to renew your
 dues in August of each year. To participate in this program, please sign below:


 X___________________________________________ Printed name: ________________________________________

                               Your Continued Support is Greatly Acknowledged!
 FOR YOUR RECORDS, PLEASE NOTE THAT THE REVENUE RECONCILIATION ACT OF 1993 STATES THAT ASSOCIATION DUES USED FOR
 LOBBYING ACTIVITIES ARE NOT DEDUCTIBLE AS A BUSINESS EXPENSE. 1.5% OF YOUR HCMA DUES FOR 2012 CANNOT BE DEDUCTED AS A
 BUSINESS EXPENSE FOR FEDERAL INCOME TAX PURPOSES. The estimated portion of your 2012 dues dedicated to lobbying activities for
 HCMA is 1.5%.

 ASSOCIATION DUES ARE NOT DEDUCTIBLE AS A CHARITABLE CONTRIBUTION FOR FEDERAL INCOME TAX PURPOSES, BUT MAY BE PARTIALLY
 DEDUCTIBLE AS A BUSINESS EXPENSE. PLEASE CONSULT YOUR TAX ADVISOR.

				
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posted:9/14/2012
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