St. Charles SCRIP Order Form / Receipt
STORE	%	$	QTY	DUE	STORE	%	$	QTY	DUE
American Eagle	8%	$25			Kwik Trip	4%	$20
Barnes & Noble	9%	$10			Menards	4%	$25
Ben Franklin	10%	$20			Mrs Fields Cookies	25%	$5
Best Buy	2%	$25			Office Max	4%	$25
Burger King	4%	$5			Old Navy	9%	$20
Cabela’s	8%	$25			Olive Garden/Red Lobster	9%	$25
Casual Corner	19%	$25			Payless	13%	$20
Chi-Chi’s	17%	$10			Pedretti’s Kwik Stop	4%	$25
Chuck E. Cheese	8%	$10			Pizza Hut	9%	$5
Culver’s	10%	$5			Quillin’s	3%	$50
Gander Mountain	8%	$25			Sears	4%	$25
GAP	9%	$25			Shopko	4%	$25
Home Depot	3%	$25			Wendy’s	9%	$10
JC Penney	5%	$25
K Mart	2%	$25
Kohl’s	5%	$25			Sub-Total this page

Name: Phone: _________________________________________

Received By: Sold by: Date:

Make checks payable to: St. Charles SCRIP Fund

Grand Total Due	$
cash/check#

Additional Comments:

The profits from the SCRIP program are to be used to benefit the Parish, both the Church and School. You may designate ½ of the profit from each sale for a specific use. Below are lists of the current options you may choose from. The remaining profit, and the undesignated profits will be transferred periodically to the Parish general checking account.

1/2 of the discount (profit) may be applied to one of the following:

� Tuition Credit or CCD Fee for

� Church Building Fund

� Education Trust Fund

SCRIP is like cash: lost, stolen or expired SCRIP cannot be replaced.

Percentages are subject to change. Form revised 2/13/04