Arisia, Inc. Expenditure form (Rev 3/98)

Arisia Income Form (Rev 9/98)
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This area for office use only:

Account:________________ Date Ent:_________________

One Kendall Sq., PMB 322, Building 600
Cambridge, Massachusetts 02139

Arisia, Inc. is a non-profit, tax exempt and tax deductable organization as certified by IRS code 501-c(3). Mass State Sales Tax Exemption Number: 043-031-143.

Your Name:_______________________________ Income Date:__________ Today's Date:_________

Type of income (check all that apply): convention registration___, advertising income___, donation ___,

dealer's table ___, corporate membership ___, other (specify):_________________________________

If income is an advertisment, dealer's table, or donation write purchaser info below or attach cover letter.

Purchaser Name:___________________________________________ Phone #:____________________

Address:_____________________________________________________________________________

_____________________________________________________________________________

City ___________________________________________________ State______ Zip_____________

Detailed List of Income:

From/Purchaser                                    Item       Amount

_____________________________________________________________________________ _________________ __________________________

Check here if continued on back ___

                                              Total Amount:____________

Submitted (Corporate Officer/Committee Head//Convention Officer/Division Head/Department Head):

Name:____________________________________ Signature:_________________________________

Treasurer's Approval (Signature): _______________________________________ Date: ____________