GRADES​ ​K-5​ ​LUNCH​ ​MENU DECEMBER​ ​2017 Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

All​ ​entrees​ ​can​ ​be​ ​substituted for​ ​a​ ​WG​ ​PBJ​ ​Graham Cracker​ ​Sandwich​ ​or ​ ​Tossed​ ​Vegetarian​ ​Salad.

Saturday

1

2

*Cheese​ ​Pizza ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Baby​ ​Carrots ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Apple​ ​Slices Ice​ ​Cream​ ​Cup

3

4

5

6

7

8

*Cheesy​ ​Bread​ ​Stick Marinara​ ​Dipping​ ​Sauce Cucumbers Peaches

Chicken​ ​Nuggets Mac​ ​&​ ​Cheese Broccoli​ ​Florets Apple​ ​Slices

Cheeseburger Sweet​ ​Potato​ ​Fries Pickles 100%​ ​Frozen​ ​Fruit​ ​Bar

Chicken​ ​Patty​ ​Sandwich Baked​ ​Chips Carrots Whole​ ​Fruit

*Cheese​ ​Pizza Seasoned​ ​Edamame Cookie Fruit​ ​of​ ​the​ ​Day

13

14

15

16

Sweet​ ​&​ ​Sour​ ​Chicken Turkey​ ​&​ ​Cheese​ ​Hoagie WG​ ​Vegetable​ ​Rice Carrot​ ​Stick​ ​w/​ ​Dipping​ ​Sauce Mini​ ​Vegetable​ ​Egg​ ​Roll Apple​ ​Chips Mixed​ ​Fruit Grapes

*Cheese​ ​Pizza Bean​ ​Salad Mini​ ​Ice​ ​Cream​ ​Sandwich Pears

*Indicates​ ​Vegetarian​ ​Meal

23

10

11

12

French​ ​Toast​ ​Sticks Hash​ ​Browns Turkey​ ​Bacon 100%​ ​Fruit​ ​Juice

*Pasta​ ​Alfredo Garlic​ ​Bread​ ​Stick Broccoli​ ​w/​ ​Ranch Peaches

17

18

19

20

21

22

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

24

25

26

27

28

29

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break​.

School​ ​Closed Winter​ ​Break

All​ ​parents/guardians​ ​of​ ​children​ ​with 150​ ​&​ ​468/486​ ​BUILDINGS food​ ​allergies​ ​must​ ​have​ ​their​ ​child's DAILY​ ​BREAKFAST​ ​MENU physician​ ​complete​ ​and​ ​return​ ​a Cold​ ​Cereal​ ​&​ ​Milk,​ ​Juice,​ ​Yogurt,​ ​Mini physician​ ​form​ ​annually​ ​to​ ​the​ ​school Bagel,​ ​WG​ ​Muffin,​ ​and​ ​Fresh​ ​Fruit nurse.​ ​ ​The​ ​nurse​ ​will​ ​communicate allergy​ ​information​ ​to​ ​the​ ​Food​ ​Service Department.​ ​ ​Please​ ​ask​ ​your​ ​school nurse​ ​for​ ​the​ ​physician​ ​form.

31

NOTES

9

30

500​ ​BUILDING WEEKLY​ ​BREAKFAST​ ​MENU Mon:​ ​Scrambled​ ​Eggs Tues:​​ ​French​ ​Toast​ ​Sticks Wed:​​ ​Sausage/Egg​ ​on​ ​Roll Thurs:​ ​Pancakes Fri:​ ​Egg/Cheese​ ​on​ ​Roll

Menu​ ​Key

BREAKFAST​ ​PRICES

LUNCH​ ​PRICES

MILK​ ​OPTIONS

MENU​ ​ITEMS

WG​ ​=​ ​Whole​ ​Grain WW​ ​=​ ​Whole​ ​Wheat MG​ ​=​ ​Multi​ ​Grain

Breakfast​ ​K-12​ ​=​ ​$2.00. For​ ​qualified​ ​applicants, breakfast​ ​K-12​ ​=​ ​$.30.

Lunch​ ​K-5​ ​=​ ​$3.15. For​ ​qualified​ ​applicants, lunch​ ​K-12​ ​=​ ​$.40.

All​ ​lunches​ ​include​ ​a​ ​choice​ ​of fat-free​ ​white,​ ​strawberry,​ ​or chocolate​ ​milk.

All​ ​items​ ​typically​ ​fried​ ​are To​ ​make​ ​payments​ ​to​ ​your​ ​child’s​ ​meal​ ​account, baked.​ ​ ​Menu​ ​items​ ​are view​ ​balances,​ ​and​ ​review​ ​purchases,​ ​use subject​ ​to​ ​change. MySchoolAccount.com

PAYMENTS

GRADES​ ​6-8​ ​LUNCH​ ​MENU DECEMBER​ ​2017 Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

All​ ​entrees​ ​can​ ​be​ ​substituted for​ ​a​ ​Chef​ ​Salad​ ​w/​ ​WG Cracker.

Saturday

1

2

*Cheese​ ​Pizza ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Baby​ ​Carrots ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Apple​ ​Slices Ice​ ​Cream​ ​Cup

3

4

5

6

7

8

All​ ​entrees​ ​can​ ​be​ ​substituted for​ ​a​ ​Grilled​ ​Chicken​ ​Salad​ ​w/ WG​ ​Crackers.

*Cheesy​ ​Bread​ ​Stick Marinara​ ​Dipping​ ​Sauce Cucumbers Peaches

Chicken​ ​Nuggets Mac​ ​&​ ​Cheese Broccoli​ ​Florets Apple​ ​Slices

Cheeseburger Sweet​ ​Potato​ ​Fries Pickles 100%​ ​Frozen​ ​Fruit​ ​Bar

Chicken​ ​Patty​ ​Sandwich Baked​ ​Chips Carrots Whole​ ​Fruit

*Cheese​ ​Pizza Seasoned​ ​Edamame Cookie Fruit​ ​of​ ​the​ ​Day

13

14

15

16

Sweet​ ​&​ ​Sour​ ​Chicken Turkey​ ​&​ ​Cheese​ ​Hoagie WG​ ​Vegetable​ ​Rice Carrot​ ​Stick​ ​w/​ ​Dipping​ ​Sauce Mini​ ​Vegetable​ ​Egg​ ​Roll Apple​ ​Chips Mixed​ ​Fruit Grapes

*Cheese​ ​Pizza Bean​ ​Salad Mini​ ​Ice​ ​Cream​ ​Sandwich Pears

*Indicates​ ​Vegetarian​ ​Meal

23

10

11

12

All​ ​entrees​ ​can​ ​be​ ​substituted for​ ​a​ ​Chicken​ ​Caesar​ ​Salad w/​ ​WG​ ​Crackers.

French​ ​Toast​ ​Sticks Hash​ ​Browns Turkey​ ​Bacon 100%​ ​Fruit​ ​Juice

*Pasta​ ​Alfredo Garlic​ ​Bread​ ​Stick Broccoli​ ​w/​ ​Ranch Peaches

17

18

19

20

21

22

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

24

25

26

27

28

29

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break​.

School​ ​Closed Winter​ ​Break All​ ​parents/guardians​ ​of​ ​children​ ​with food​ ​allergies​ ​must​ ​have​ ​their​ ​child's physician​ ​complete​ ​and​ ​return​ ​a physician​ ​form​ ​annually​ ​to​ ​the​ ​school nurse.​ ​ ​The​ ​nurse​ ​will​ ​communicate allergy​ ​information​ ​to​ ​the​ ​Food Service​ ​Department.​ ​ ​Please​ ​ask​ ​your school​ ​nurse​ ​for​ ​the​ ​physician​ ​form.

31

NOTES

9

30

500​ ​&​ ​515​ ​BUILDING WEEKLY​ ​BREAKFAST​ ​MENU ​ ​Mon:​ ​Scrambled​ ​Eggs ​ ​Tues:​​ ​French​ ​Toast​ ​Sticks ​ ​Wed:​​ ​Sausage/Egg​ ​on​ ​Roll ​ ​Thurs:​ ​Pancakes ​ ​Fri:​ ​Egg/Cheese​ ​on​ ​Roll

Menu​ ​Key

BREAKFAST​ ​PRICES

LUNCH​ ​PRICES

MILK​ ​OPTIONS

MENU​ ​ITEMS

WG​ ​=​ ​Whole​ ​Grain WW​ ​=​ ​Whole​ ​Wheat MG​ ​=​ ​Multi​ ​Grain

Breakfast​ ​K-12​ ​=​ ​$2.00. For​ ​qualified​ ​applicants, breakfast​ ​K-12​ ​=​ ​$.30.

Lunch​ ​6-8​ ​=​ ​$3.25. For​ ​qualified​ ​applicants, lunch​ ​K-12​ ​=​ ​$.40.

All​ ​lunches​ ​include​ ​a​ ​choice​ ​of fat-free​ ​white,​ ​strawberry,​ ​or chocolate​ ​milk.

All​ ​items​ ​typically​ ​fried​ ​are To​ ​make​ ​payments​ ​to​ ​your​ ​child’s​ ​meal​ ​account, baked.​ ​ ​Menu​ ​items​ ​are view​ ​balances,​ ​and​ ​review​ ​purchases,​ ​use subject​ ​to​ ​change. MySchoolAccount.com

PAYMENTS

GRADES​ ​9-12​ ​LUNCH​ ​MENU DECEMBER​ ​2017 Sunday

Monday

Tuesday

Wednesday

*Indicates​ ​vegetarian Monday​ ​entree​ ​rotation​ ​items Tuesday​ ​entree​ ​rotation​ ​items meal include​ ​pepperoni​ ​pizza, include​ ​meat-lovers​ ​pizza, chicken​ ​craze,​ ​a​ ​chicken​ ​wrap, tacos,​ ​taco​ ​salad,​ ​or​ ​specialty or​ ​specialty​ ​salads. salads.

Thursday

Friday

Wednesday​ ​entree​ ​rotation Thursday​ ​entree​ ​rotation items​ ​include​ ​buffalo​ ​chicken items​ ​include​ ​pepperoni​ ​pizza, pizza,​ ​specialty​ ​burger,​ ​a​ ​cold chicken​ ​craze,​ ​a​ ​chicken​ ​deli cut​ ​combo,​ ​or​ ​specialty​ ​salads wrap,​ ​or​ ​specialty​ ​salads.

All​ ​entrees​ ​can​ ​be​ ​substituted for​ ​a​ ​Chef​ ​Salad​ ​w/​ ​WG Cracker.

Saturday

Friday​ ​entree​ ​rotation​ ​items include​ ​specialty​ ​salads​ ​and other​ ​options​ ​selected​ ​by​ ​our Food​ ​Service​ ​cooks.

1

2

*Cheese​ ​Pizza Bean​ ​Salad 100%​ ​Frozen​ ​Fruit​ ​Bar

3

4

5

6

7

8

All​ ​entrees​ ​can​ ​be​ ​substituted for​ ​a​ ​Grilled​ ​Chicken​ ​Salad​ ​w/ WG​ ​Crackers.

Fried​ ​Chicken Buttermilk​ ​Biscuit Vegetarian​ ​Baked​ ​Beans Fresh​ ​Fruit​ ​of​ ​the​ ​Day

Turkey​ ​Ranch​ ​Wrap Fresh​ ​Broccoli Baked​ ​Chips Peaches

Hot​ ​Ham​ ​&​ ​Cheese Pretzel​ ​Roll Sweet​ ​Potato​ ​Fries Cucumber​ ​Slices Mixed​ ​Fruit

Bacon​ ​Cheddar​ ​Burger Waffle​ ​Fries Carrot​ ​Sticks​ ​w/​ ​Ranch Orange​ ​Slices

*Cheese​ ​Pizza Chickpea​ ​Salad Fresh​ ​Fruit Ice​ ​Cream

10

11

12

13

14

15

All​ ​entrees​ ​can​ ​be​ ​substituted for​ ​a​ ​Chicken​ ​Caesar​ ​Salad w/​ ​WG​ ​Crackers.

Boneless​ ​Chicken​ ​Wings Dipping​ ​Sauce Crispy​ ​Fries Apple

Beef​ ​Tacos Shredded​ ​Lettuce,​ ​Salsa,​ ​and Cheddar​ ​Cheese Rice Oranges

Italian​ ​Hoagie Cucumber​ ​Salad Baked​ ​Chips Fruit​ ​of​ ​the​ ​Day

Chicken​ ​Stir​ ​Fry​ ​Bowl WG​ ​Rice Mixed​ ​Vegetables Fortune​ ​Cookie Fresh​ ​Fruit

*Cheese​ ​Pizza Tossed​ ​Salad Ice​ ​Cream​ ​Cup Fruit​ ​of​ ​the​ ​Day

17

18

19

20

21

22

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

24

25

26

27

28

29

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break

School​ ​Closed Winter​ ​Break All​ ​parents/guardians​ ​of​ ​children​ ​with food​ ​allergies​ ​must​ ​have​ ​their​ ​child's physician​ ​complete​ ​and​ ​return​ ​a physician​ ​form​ ​annually​ ​to​ ​the​ ​school nurse.​ ​ ​The​ ​nurse​ ​will​ ​communicate allergy​ ​information​ ​to​ ​the​ ​Food Service​ ​Department.​ ​ ​Please​ ​ask​ ​your school​ ​nurse​ ​for​ ​the​ ​physician​ ​form.

31

NOTES

9

16

23

30

535​ ​BUILDING WEEKLY​ ​BREAKFAST​ ​MENU ​ ​Mon:​ ​Scrambled​ ​Eggs ​ ​Tues:​​ ​French​ ​Toast​ ​Sticks ​ ​Wed:​​ ​Sausage/Egg​ ​on​ ​Roll ​ ​Thurs:​ ​Pancakes ​ ​Fri:​ ​Egg/Cheese​ ​on​ ​Roll

Menu​ ​Key

BREAKFAST​ ​PRICES

LUNCH​ ​PRICES

MILK​ ​OPTIONS

MENU​ ​ITEMS

WG​ ​=​ ​Whole​ ​Grain WW​ ​=​ ​Whole​ ​Wheat MG​ ​=​ ​Multi​ ​Grain

Breakfast​ ​K-12​ ​=​ ​$2.00. For​ ​qualified​ ​applicants, breakfast​ ​K-12​ ​=​ ​$.30.

Lunch​ ​9-12​ ​=​ ​$3.40. For​ ​qualified​ ​applicants, lunch​ ​K-12​ ​=​ ​$.40.

All​ ​lunches​ ​include​ ​a​ ​choice​ ​of fat-free​ ​white,​ ​strawberry,​ ​or chocolate​ ​milk.

All​ ​items​ ​typically​ ​fried​ ​are To​ ​make​ ​payments​ ​to​ ​your​ ​child’s​ ​meal​ ​account, baked.​ ​ ​Menu​ ​items​ ​are view​ ​balances,​ ​and​ ​review​ ​purchases,​ ​use subject​ ​to​ ​change. MySchoolAccount.com

PAYMENTS

 

December   2017   K­12   Meal   Payment   Form    The   December  2017  K­12  Meal  Payment  Form   is  on  the  reverse  side  of  this  form  and  a  lunch  menu  is  available  for  reference  on   www.collegiumcharter.com .  Families  sending payments directly into school should complete the form and  return  it  to  school  with  payment  as  soon  as  possible,  as  processing  may  take  up  to  five  days  before  the  payment  is  available  for  your  child.  Please  use  one  form  per  student  and  remember  to  include  their  name,  grade,  homeroom  teacher,  and  PIN.  A  student’s  PIN never changes and new students receive their PINs during their first week of school.  MySchoolAccount  i s   the   faster,   preferred   way   to   fund   meal   accounts   –  and   there’s   no   need   to   complete   or   return   forms!    CCS  families  have  access  to   www.MySchoolAccount.com ,  a  web­based  application  that’s  very  easy  to  use.  Families  can  make  an  online  payment  up  until  midnight from their checking or savings accounts and have deposits made for the  very  next  day  into  all  of  their  children’s  meal  accounts.  You  can  see  what  your  child  has  eaten  over  the  last 30 days,  check  account  balances,  move  money  between  your  children’s  meal  accounts,  and  request  an  automatic  email  notification  for low account balances.  In order to take advantage of this online feature, visit  www.MySchoolAccount.com  and  follow  the  prompts  to  create  a   Parent  Account .  You  will  need  to  know  your  child’s  birth  date  and  student  ID  (their  lunch  PIN).  It  takes  less  than  ten  minutes  to  set  up  –  it  really  is  easy!  Student  records  are  updated  nightly  and  all  transactions  occur  over  secure connections.  If you’ve already set up an account for your child, your login is still valid as  it   does   not   change   from   school   year   to   school   year.    Families  may  apply  for the  Free and Reduced Price School Meal Program at any time during the school year.  The  Free  and  Reduced  Price  School  Meals   Family  Application  is  available  in  the   Food  Service  section  of  the  CCS  website  at  www.collegiumcharter.com  or  from  our  Main  Offices  on  campus,  or  you  can  access the information and apply online at  www.humanservices.state.pa.us/compass . T   his   is   a  family   application;  o   nly   one   per   household   need   be   submitted.    As  a  reminder,  if  your  child  has  an  allergy  to  any  food  product,  a doctor’s note must be submitted to the Food  Service  Department to be kept on file.   In accordance with  PA Department of Education regulations, please submit an  updated   doctor’s   note   at   the   beginning   of   each   school   year.    ● Please   allow   five   (5)   days   for   payments   sent   to   school   to   be   posted   to   your   child’s   account.   ● K­3  lunch purchases must be prepaid, do not send cash.   Due to the volume of purchases cash cannot be accepted  in   the   K­3   lunch   lines.   ● Payments  that  come  in  on  a  daily  basis  will  not  be  available  for your child as they are not processed by lunchtime.  Payment  to  a  student’s  account  should  be  prepaid  monthly  unless  this  creates  a  financial hardship for your family.  If   so,   please   pay   bi­weekly   or   weekly,   not   daily.  ● The  lunch  meal  cost  for  grades   K­5  is  $3.15,  grades  6­8  is  $3.25,  and  grades  9­12  is  $3.40  with  increases  correlating   to   larger   portions   of   food.   ● Students  eligible for free or reduced lunches/breakfasts are only eligible for the meal­of­the­day or the peanut butter  &   jelly   meal.    They   may   not   choose   any   a  la   carte   items   in   lieu   of   the   meal.   ● Returned checks will incur an additional returned check fee and all future payments to CCS must be paid by cash or  money   order.  ● Students  with  zero/negative  balances  may  receive  alternative  meals  as  indicated  in  the   Meal  Payment/Charging  Policy .  ● If   prepaid,   milk   may   be   charged   to   a  student’s   account.  M   ilk   is   $.70 .  ● The  breakfast  meal  is  $2.00  and  it  is  preferable  that  students  use  their meal account for breakfast meals.  A K­6  student’s  account  may  be  used  for  meal­of­the­day  purchases  only,  not  for  a  la  carte  items*.  Separate  cash  and  carry  a  la  carte  items  are  available  from  $.50  to  $3.50.  Breakfast  is  available  for  grades  K­5  from  7:40am  until  8:10am   and   for   grades   6­12   from   7:05am   to   7:25am.    If   you   have   any   questions,   please   contact   Mr.   Mike   Ely,   our   Food   Service   Manager,   at   610­903­6371   or   [email protected].     *HS   students   may   use   their   Food   Service   accounts   to   make   a  la   carte   purchases.   Collegium   is   piloting   a  new   program  allowing   MS   students   to   make   a  la   carte   purchases   using   their   Food   Service   accounts.  MEAL   PAYMENT   FORM                     

 

 

December   2017   K­12   Meal   Payment   Form    Please  return  this  page  with  payment  as  soon  as  possible.  To  ensure  availability,  please   allow  5  school  days  for  the  payment to be posted to your child’s account .  For next day availability, use  www.MySchoolAccount.com . Alternative lunches  may   be   provided   for   students   with   negative   account   balances,   per   the   CCS  M   eal   Payment/Charging   Policy .   

Complete   this   section   and   remit   with   payment   in   a  sealed   envelope. 

 S   tudent’s   Name :   G   rade : 

 B   uilding   Number : ⃣   150    ⃣468/486    ⃣500    ⃣515    ⃣535 

 H   omeroom   Teacher : 

 S   tudent’s   Food   Service   PIN : 

 A   mount   Paid : 

 D   ate   Submitted : 

Calculate   Your   Payment*  * The   dates   below   are   provided   solely   to   assist   families   in   calculating   payments.    They   do   not   correspond   to   a  day   when   a  child   may/may   not   purchase   a  meal   of   the   day   or   milk.    Please   circle   all   the   days   you   are   ordering  L   unch   With   Milk   December  1     4  5  6  7  8  11   12   13   14   15    Please   circle   all   the   days   you   are   ordering  B   reakfast   With   Milk   December  1     4  5  6  7  8  11   12   13   14   15  Please   circle   all   the   days   you   are   ordering  J   ust   Milk   December  1     4  5  6  7  8  11   12   13   14   15 

 

 

Please   Calculate   the   Amount   of   Money   Due:  Lunches   w/   Milk   by   Grade/   ** Cost :  K   ­6   =  $3.15    7   /8   =  $3.25    9   ­12  =     $3.40 

  Number   of   Lunches   w/   Milk   _____________________ (K­5)   11   Lunches   @  $3.15   per   day   =  $34.65   (6­8)   11   Lunches   @  $3.25   per   day   =  $35.75  (9­12)   11   Lunches   @  $3.40   per   day   =  $37.40 

Number   of   Reduced   Lunches   w/   Milk   _____________

           x *  *Cost  =   

___________ 

           x  $.40   = 

___________ 

11   Lunches   @  $.40   per   day   =  $4.40  (  approved   reduced   recipients   only) 

Number   of   Breakfasts   w/   Milk   ___________________                        x  $2.00   =          ___________  11  B   reakfasts   @  $2.00   per   day   =  $22.00  Number   of   Reduced   Breakfasts   w/   Milk   ____________

            x  $.30   =            ___________ 

11   Breakfasts   @  $.30   per   day   =  $3.30  (  approved   reduced   recipients   only) 

Number   of   Milks   _______________________________ 11  M   ilks   @  $.70   per   day   =  $7.70   

            x  $.70   = 

___________ 

            Total   Due 

___________ 

 

Please  make  checks/money  orders  payable  to   Collegium  Charter  School  and  please  indicate  your  child’s food service PIN  on  the  memo  line.  Return  this  form  with  payment  in  an  envelope  to  CCS,   allowing  5  school  days  for  the  payment  to  be  posted  and  available  in  your  child’s  meal  account.  For  overnight  posting  and  availability,  use   www.MySchoolAccount.com .  Alternative  lunches  may  be  provided  for  students  with  negative  account  balances,  per  the  CCS   Meal  Payment/Charging  Policy .   

For   Office   Use   Only  Check   #:  

Money   Order   #:  

Cash : 

Amount : 

Date : 

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