Tootsie Roll Order Form

Complete this form and mail checks to the Tootsie Roll chairman, John Gehlsen:

John Gehlsen, Tootsie Roll Chairman

4837 Meadow Dr, Black Hawk, SD 57718
605-391-3939
[email protected]

Council Name: *

Council Number: *

RECIPIENT #4: during

Council Point of Contact Name *

First

Last

Council Point of Contact Address *

Address Line 1

Address Line 2

City

State

Zip Code

How many cases of Tootsie Rolls do you want to order for the coming year? *

PART 1: Calculation of Amount Available to Local Council from the Drive

Total amount collected during your local drive: *

(Mail a check for this amount to John Gehlsen, 4837 Meadow Dr, Black Hawk, SD 57718)

Number of cases of Tootsie Rolls purchased by your council this year: *

Total cost to council for Tootsie Rolls

(one case is $23)

Net amount of local drive after deducting costs:

Local council's 80% share available to divide for local donations:

(The amount your council may distribute between recipients).

State council's 20% share:

PART 2: Local donation(s) made by dividing local council's 80% share amount the following recipients:

RECIPIENT #1: Name of person(s) or organization receiving donations:

RECIPIENT #1: Amount of donation:

(round to the nearest dollar)

RECIPIENT #2: Name of person(s) or organization receiving donations:

RECIPIENT #2: Amount of donation:

(round to the nearest dollar)

RECIPIENT #3: Name of person(s) or organization receiving donations:

RECIPIENT #3: Amount of donation:

(round to the nearest dollar)

RECIPIENT #4: Name of person(s) or organization receiving donations:

RECIPIENT #4: Amount of donation

(round to the nearest dollar)

RECIPIENT #5: Name of person(s) or organization receiving donations:

RECIPIENT #5: Amount of donation:

(round to the nearest dollar)

RECIPIENT #6: Name of person(s) or organization receiving donations:

RECIPIENT #6: Amount of donation:

(round to the nearest dollar)

RECIPIENT #7: Name of person(s) or organization receiving donations:

RECIPIENT #7: Amount of donation:

(round to the nearest dollar)

RECIPIENT #8: Name of person(s) or organization receiving donations:

RECIPIENT #8: Amount of donation:

(round to the nearest dollar)

RECIPIENT #9: Name of person(s) or organization receiving donations:

RECIPIENT #9: Amount of donation:

(round to the nearest dollar)

RECIPIENT #10: Name of person(s) or organization receiving donations:

RECIPIENT #10: Amount of donation:

(round to the nearest dollar)

RECIPIENT #11: Name of person(s) or organization receiving donations:

RECIPIENT #11: Amount of donation:

(round to the nearest dollar)

RECIPIENT #12: Name of person(s) or organization receiving donations:

RECIPIENT #12: Amount of donation:

(round to the nearest dollar)

RECIPIENT #13: Name of person(s) or organization receiving donations:

RECIPIENT #13: Amount of donation:

(round to the nearest dollar)

RECIPIENT #14: Name of person(s) or organization receiving donations:

RECIPIENT #14: Amount of donation:

(round to the nearest dollar)

RECIPIENT #15: Name of person(s) or organization receiving donations:

RECIPIENT #15: Amount of donation:

(round to the nearest dollar)

PART 1: Calculation of Amount Available to Local Council from the Drive

PART 2: Local donation(s) made by dividing local council's 80% share amount the following recipients:

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