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The Romans destroyed the Temple in Jerusalem in 70AD. Visit the only remnant of the Temple, the Western Wall (Wailing Wall). Immediately above the Western Wall is the Temple Mount. Hosts: Dr. John Brock Senior Pastor Highland Baptist Church Florence, AL And Friends of Nazareth Baptist School March 19-30, 2017 Tour limit is 37 guests Register by august 31, 2016 for best rate cost, including taxes, is $3950, if registered by August 31, 2016. If Registered on September 1, 2016 – October 31, 2016, Cost, including taxes, is: $4200. *Taxes are subject to change – Travelers will be asked to pay any airline tax fees that exceed those included in the package Transformed 2017 Holy Land Tour Brochure and Terms and Conditions Transformed “And be not conformed to this world, but be ye transformed by the renewing of your mind, that ye may prove what is that good, and acceptable, and perfect, will of God. Romans 12:2

7 Churches of Revelation · I made my first trip to the Holy Land in 2013. I was profoundly transformed by the experience. The Holy Land’s significance to Christianity is unmatched

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Page 1: 7 Churches of Revelation · I made my first trip to the Holy Land in 2013. I was profoundly transformed by the experience. The Holy Land’s significance to Christianity is unmatched

The Romans destroyed the Temple in Jerusalem in 70AD. Visit the only

remnant of the Temple, the Western Wall (Wailing Wall).

Immediately above the Western Wall is the Temple Mount.

Hosts:

Dr. John Brock

Senior Pastor

Highland Baptist Church

Florence, AL

And

Friends of Nazareth

Baptist School

March 19-30, 2017

Tour limit is 37 guests

Register by august 31, 2016 for

best rate

cost, including taxes, is $3950, if

registered by

August 31, 2016.

If Registered on September 1, 2016

– October 31, 2016, Cost,

including taxes, is: $4200.

*Taxes are subject to change –

Travelers will be asked to pay

any airline tax fees that

exceed those included in the

package

Transformed

2017 Holy Land Tour Brochure and Terms and Conditions

Transformed

“And be not conformed to this world, but be ye transformed by the

renewing of your mind, that ye may prove what is that good, and

acceptable, and perfect, will of God. Romans 12:2

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Invitation from Dr. Brock,

I made my first trip to the Holy Land in 2013. I was profoundly transformed by the experience. The

Holy Land’s significance to Christianity is unmatched. It is the place of our Savior’s birth, childhood,

ministry, death, burial and resurrection. It is the place to which He will return.

I invite you to travel with me from March 19 – 30, 2017. You can expect to tour holy sites, meet Christian

brothers and sisters, minister to a group of Evangelical Christians through a time of prayer walking and

serving. We are traveling in partnership with Friends of Nazareth (www.friendsofnazareth.org) a ministry

that is dedicated to enriching and enlarging the evangelical witness of the Nazareth Baptist School in the

hometown of Jesus.

This is a tour designed to enrich every believer’s walk with Jesus and expand her or his understanding of

the Old and New Testaments. We will be met by our Christian guide upon arrival in Tel Aviv. He will

stay with us the entire tour and will ensure that our every need is met. All hotels are top rated, four stars

or higher. We will travel by a modern coach tour bus. I will be teaching at points along the tour route.

Mosaic in the Garden Tomb area.

Our journey will include stops:

Around and on the Sea of Galilee to learn about The Ministry of Jesus – Around The Lake. We

will enjoy a time of spiritual reflection and meditation at sights such as the Mount of Beatitudes

Matthew 5: 1-15); Capernaum, the base of Jesus’ ministry (Mark 1:31-38); Tabgha, the traditional

site of the miracle of the Loaves and Fishes (Mark 6:30-44); a drive along the Via Maris where

Jesus fed His disciples after his resurrection (John 21). We will visit the town of Magdala, where

Jesus surely visited, preached, healed and met Mary Magdalene. We will stand in the 1st Century

synagogue where Jesus likely worshipped and taught. Our travels will include visits to the Jordan

River where group members may choose to experience baptism in the Jordan River. We will seek

to understand what the Jewish people of 2000 years ago expected of the Messiah and how that was

fulfilled in Jesus. We will travel the mountains of the region to the most likely place of the

transfiguration. We will ride on the Sea of Galilee and experience the beauty, majesty and mystery

of the area where Jesus spent most of his ministry.

In the hometown of Jesus, Nazareth. We will stop in Cana (John 2:1-12), the sight of Jesus’

first miracle, as we ascend to Nazareth. We will visit the Nazareth Baptist School and explore

Jesus’ hometown, including sights such as: Mary’s Well, St. Gabriel’s Church, the Church of the

Annunciation and Nazareth Village, a 1st Century re-created village giving us a visual of life

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during the time of Jesus. We will visit Mount Precipice (Luke 4:16-30) and take in the

breathtaking views of the Jezreel Valley. Time and schedule permitting, the group may worship at

the Local Baptist Church which meets in the Nazareth Baptist School. It is the largest of the

evangelical churches in the Holy Land.

In and around the Jezreel Valley. The Valley of Armageddon (Revelation 16:15-16) at Megiddo

is a place that reminds us that God has a plan for the end of days. We will continue to Mt. Carmel

where Elijah prayed and God defeated 450 prophets of Baal with fire from Heaven (1 Kings 18). As

we cross the Jezreel Valley to the Eastern point, our exploration leads us to the Israelite city of

Beit Sh’ean near where King Saul and his sons were defeated by the Philistines on Mt. Gilboa (1

Samuel 31). Beit Sh’ean was along the Via Maris and later became the major Decapolis city of

Scythopolis.

From the Jordan Valley to Bethlehem. We will travel the route that Mary and Joseph most

probably traveled from Nazareth to Bethlehem. We will visit the Shepherd’s Fields Church and

caves where the angel of the Lord proclaimed the Good News of the birth of the Savior (Luke 2:8-

18). We will visit the Nativity Church in Bethlehem. Please note that the church is undergoing

heavy renovations and our activities may be limited.

In the Jewish Quarter – Jerusalem. We will seek to understand Jerusalem at the time of Jesus

as we visit the Model City at the Israel Museum. We will explore some of the places in the Jewish

quarter where Jesus encountered the Pharisees, Sadducees, Herodians and Scribes. You will walk

among the modern Jewish neighborhoods and witness their dreams fulfilled as they return to Zion

and spiritually prepare to rebuild the Temple in Jerusalem. We will walk on the original steps of

the Temple (Southern Steps), see the Hulda Gates and learn about a pilgrimage to the Holy

Temple in the time of Jesus. We will see the huge stones that were thrown down from the Temple

Mount when the Romans destroyed the Temple and left not one stone standing upon another

(Mark 13:2). We will join the Jewish people at their holiest site – the Western Wall, which is the

retaining wall of the Temple Mount and situated closest to where the Holy of Holies once stood.

Tour the tunnel beneath the city of Old Jerusalem, along the Western Wall.

Throughout Jerusalem. The group will make visits to the Mount of Olives; Palm Sunday Road

(walk if you like); Garden of Gethsemane and the Church of All Nations; St. Anne’s Church and

the Pools of Bethesda; the Via Dolorosa including the Church of the Holy Sepulcher; cross the

Kidron Valley to the home of the High Priest Caiaphas where Jesus was held and tried by the

Pharisees and Sadducee leaders of the Sanhedrin and much more.

In the Judean Desert, Dead Sea and Masada. We will meander East from Jerusalem to the

Judean desert and along the western shore of the Dead Sea. We will visit Qumran where the Dead

Sea scrolls were written over 2000 years ago. Traveling South, we will come to Masada, the

fortress built by King Herod and the site of the last Jewish resistance against the Romans in

73AD. Ascending Masada by cable car, you will be able to survey the ruins of the fortifications,

waterworks, synagogue, temples and palaces. We will make a stop at the Dead Sea, the lowest spot

on Earth. If desired, you may float in the healing waters. Please be sure to bring water proof/closed

toed shoes as the bottom of the Dead Sea is very rough. We will make a stop in Jericho to see the

Monastery of Temptation and a Sycamore Tree, symbolic of Jesus’ encounter with Zacchaeus.

From Jerusalem to the Ends of the Earth. We will make a morning visit to the Garden Tomb

to remember the resurrection of Jesus and share a special time of worship, prayer and the Lord’s

Supper. We will prepare our hearts to take the Gospel to all Nations (Matthew 28:18-20). Upon

leaving Jerusalem, we will travel to Caesarea Maritima and visit the extensive ruins of Caesarea,

an ancient port city built by King Herod and where he died (Acts 12:20-25). It later became the

seat of government of the Roman governors. It is the place where Peter proclaimed the Good News

to the Roman Centurion (Acts 9 and 25). It was here that the Gentile household of Cornelius (Acts

10) was baptized with the Holy Spirit which reconciled the Jews and Gentiles as part of the family

of Christ. Paul’s missionary journeys departed from Caesarea. We will travel along the coast to the

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ancient seaport of Jaffa (Joppa), part of modern day Tel Aviv. There we will see the home of Simon

the Tanner (Acts 10:6) and recall the biblical account of Jonah (Jonah 1:3). We hope to behold a

sunset on the Mediterranean before returning to the USA.

I will be teaching throughout the tour. Bring your Bible, camera and your journal. We will have an

Evangelical Christian guide who loves the Lord and loves to share his homeland with Holy Land visitors.

This truly is a trip of a lifetime!

Please read this brochure in its entirety. I look forward to learning that you will be joining me as we

explore God’s Word and walk upon the soil of the Holy Land!

John Brock

Senior Pastor

Highland Baptist Church

Tour Host

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Church at the Mount of Beatitudes, Galilee Area.

Inside the temple in Capernaum. Capernaum was the headquarters of

Jesus ministry. It was the home of Peter and the place of many miracles

that Jesus performed.

Please Read

Important

Information

Each tour member must hold

a US Passport that is valid for

up to six months following the

scheduled return to the

United States. It is the tour

member’s responsibility to

secure a valid passport. The

passport information will be

needed to secure tour and trip

details.

All rates are based upon

double occupancy. The airline

fuel charge is subject to

change up to 30 days prior to

departure. Any additional fuel

surcharges will be the

responsibility of the traveler.

Travel insurance is not

included in the tour package.

Each traveler is required by

the State of Israel to have

international health

insurance; this is best

acquired through travel

insurance. Therefore, each

traveler must purchase travel

insurance. It is available

online through a number of

internet sites. It is also

available through the travel

agent that handles the flights.

Details can be provided upon

request.

Tour Features

Round trip air transportation from Nashville, Tennessee. (Additional routes may be purchased, however, the cost as quoted in

this brochure may not apply). Additional costs to upgrade to Economy Plus, Business or First Class are the responsibility of

the traveler.

Deluxe and first class hotels, four stars or higher.

Land transportation will be via a deluxe, private motor coach.

Christian, English speaking guide.

Breakfast, lunch and dinner included.

Entrance fees to all sites on the itinerary included.

Daily Biblical teaching.

Please note that the itinerary is flexible. Adjustments may be necessary due to circumstances beyond control, weather or other

conditions.

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Registration and Financial Information:

Registration begins no later than June 1, 2016. A non-refundable deposit of $300

per traveler is due at the time of registration. This amount, when paid, will be

deducted from the total cost of the tour.

Registration ends when trip is full (37 travelers) or November 1, 2016, whichever

comes first.

Tour price is $3950.00 for registrations received between June 1, 2016 and August

31, 2016. Registration between September 1 and October 31, 2016 is $4200.00.

Tour price includes coach airfare and double deluxe accommodation (two-

people/room); meals (except where noted); guided tours including entrance fees;

transfers and excellent Biblical teachings.

The hotel accommodations are deluxe, minimum four stars.

Departure is scheduled from Nashville, Tennessee. Alternate departure and return

cities may affect cost. All passengers must connect in Nashville.

Costs not included are: Tips, beverages; airline baggage fees, if applicable; passport

and insurance fees; laundry services; incidentals; souvenirs; internet services; and

meals not included in the itinerary.

Tips are to be paid in cash ($240.00/each) on or before the day of departure. These

tips cover drivers, tour guides, restaurants and routine hotel services.

A no interest plan is available for fees less the deposit, for registration that is

received by July 31, 2016. The plan will be $456.25/month for eight months with

the first payment due at the time of registration ($300, plus $456.25 = $756.25) and

payments due on the first day of each month of July ($456.25), August ($456.25),

September ($456.25), October ($456.25), November ($456.25), December

($456.25) and January ($456.25). Participants who register in July will be required

to pay all payments due up to the point of the day of registration. Thereafter,

payments will be due on the first day of the respective month. No payment plan is

available for those who register after July 31, 2016. Payments are not

refundable.

Checks should be made to: Transformed Holy Land Tours, LLC. Payments may be

mailed to THLT, 6440 Hampton Highlands Drive, Cumming, GA 30041 or paid in the

Office of the Pastor at Highland Baptist Church, 219 Simpson Street, Florence, AL

35630.

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Tour Conditions and Agreement

1. Agreement. The terms set forth in this Tour Conditions and Agreement form a Binding Contract

when Transformed Holy Land Tours, LLC receives your signed application and deposit. Your

submission of the Tour Registration Form and payment of the deposit constitutes passenger

acceptance of all terms, conditions, assumptions of risk, and releases from liability set forth in the

Tour Conditions and Agreement.

2. Price. Tour price of $3,9500.00, provided that registration and the deposit is received on or before

August 31, 2016. Thereafter, through the final date of registration, the amount is $4200. Please see

information regarding costs that are located in this Brochure publication.

3. Deposit. A non-refundable deposit of $300.00 is due at the time of registration.

4. Travel Medical Insurance. This is required by the Department of Tourism of Israel. Insurance is

available through VIP Travel ([email protected]) or online. Each traveler must provide a

copy of her or his medical/travel insurance verification to Transformed Holy Land Tours, LLC.

5. Payment. You may make payments to Transformed Holy Land Tours, LLC on or before due dates.

Failure to make the required payments may result in forfeiture of reservation and payments made

to date. Please read ALL of the information in the Holy Land Brochure to ensure that you

understand the terms, conditions and risks.

6. Cancellation of Reservation. If you cancel for any reason prior to October 31, 2016, you will be

refunded any money paid over and above the $300.00 non-refundable deposit. Cancellation on

November 1 or later will result in a cancellation fee of 100% of the total cost. These cancellation

fees are firm. Thus, Transformed Holy Land Tours, LLC urges you to purchase Travel Insurance. It

may be purchased directly from a travel agent or service provider of choice. Transformed Holy Land

Tours, LLC is not responsible for offering travel insurance.

7. Tips. Your tips for guides, drivers, porters, hotel personnel, dining room staffs, etc. are NOT

included in the price of the tour. A $240 cash payment for tips is due on or before the date of

departure. Transformed Holy Land Tours, LLC hosts will handle distribution of all tips during the

tour.

8. Accommodations. All accommodations are deluxe standard. Price is based upon double

occupancy, two persons to a room. Transformed Holy Land Tours, LLC will assist will locating a

roommate for you if you do not have one designated. If this is not possible or not preferred, an

additional fee for single occupancy will be charged. The single occupancy rate requires an

additional $750.00 fee.

9. Meals. Your meals are covered as stated in the Brochure.

10. Guide. Your guides will be licensed and English speaking. They will ensure that all entrance fees

are paid to sights included in the tour.

11. Items not included. Beverages at meals, other than those provided as a part of the meal package.

Personal items such as laundry. Snacks and beverages. Additional airline baggage charges.

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Passport/Visa fees. Increases in fares/taxes. Souvenirs and other personal purchases. Internet

access. Room service.

12. Airline Arrangements. Your airline arrangements will be finalized and your ticket written by VIP

Travel, Tallahassee, Florida. Once your ticket is written, it cannot be rewritten or refunded. Your

flight times are subject to change without advance notice. Neither VIP Travel nor Transformed Holy

Land Tours, LLC is responsible for changes and/or delays in airline schedules and does not

reimburse passengers for expenses resulting from delays. Note: Your travel insurance may cover

such expenses, if incurred. Tours may be lengthened or shortened due to airline changes or other

unforeseen conditions or circumstances. In the event of an increase in airline fare, the cost is the

passenger’s responsibility. Any upgrade cost is the sole responsibility of the passenger. Any fuel

surcharge imposed by the airline after the published price will be the sole responsibility of the

passenger.

13. Itinerary and Possible Changes to Itinerary. Transformed Holy Land Tours, LLC reserves the right

to alter the published itinerary at its sole discretion without advance notice and/or while the tour is

in progress.

14. Possible Cancellation of Tour. Transformed Holy Land Tours, LLC reserves the right to withdraw,

cancel or change the tour, in whole or in part, at any time, at its sole discretion. In the event of the

tour being cancelled for unforeseen circumstances, refunds will be paid first by the travel insurance

and secondly by Transformed Holy Land Tours, LLC, less reservation fees and any other non-

refundable fees, e.g. airlines may provide credit instead of refund.

15. Possible Revocation of Right to Travel Before or During. Transformed Holy Land Tours, LLC

reserves the right to refuse or revoke travel to anyone who is determined to be, in the sole judgment

of Transformed Holy Land Tours, LLC, incapable of group travel. Every traveler needs to be fit

enough to handle walking, often on rough terrain, flying lengthy distances, tolerating foreign

conditions, etc. If this determination is made while the tour is in progress, Transformed Holy Land

Tours, LLC reserves the right to send any passenger home early. In such cases, there is no refund for

any unused services and the traveler is responsible for any and all additional costs that result from

the change.

16. Personal Medical Responsibility. Every traveler is responsible for ensuring that her or his shots

are up-to-date and that s/he has international medical coverage as well as no physical travel

limitation set forth by a physician. The State of Israel requires that each traveler provides

Transformed Holy Land Tours, LLC with proof of travel medical insurance.

17. Assumption of Risk in View of the Inherent Risks and Dangers of International Travel.

International travel involves certain inherent risks and dangers, including without limitation the

following:

a. Risk of accident, serious injury and even death during travel by air, bus, boat or other means of

conveyance, and at all other times during the tour.

b. Risk of negligence by private carriers or their employees used during the tour.

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c. Risk of violent attack by terrorists. Some or all of the destinations indicated in the Brochure may

be covered by travel warnings or advisories issued by the U.S. State Department before or during

the tour. Some of the destinations listed in the Brochure may present more significant risk than

others. Transformed Holy Land Tours, LLC will endeavor to take reasonable precautions to avoid

risks. However, there is no guarantee that they will be successful in doing so. Accordingly, by

signing the Registration Form, which will become a binding contract when accepted by

Transformed Holy Land Tours, LLC, the traveler is voluntarily and expressly agreeing to assume

all such risks and hold Transformed Holy Land Tours, LLC, VIP Travel and its agents, tour hosts

harmless for any injury or loss that may occur as a result of such risks, and to release them from

any and all liability, claims or causes of action that may arise from the occurrence of such risks.

Transformed Holy Land Tours, LLC and the tour hosts assume no liability whatsoever for actions

by any person, or that result for any reason, outside of the direct control of Transformed Holy

Land Tours, LLC, including but not limited to events such as strikes, revolts, terrorist actions, civil

unrest, wars, natural disasters, inclement weather, closures of airports, hotels, roadways, or the

breach of contract, negligence or misconduct of any private carrier used during the tour.

Transformed Holy Land Tours, LLC and the tour hosts are not responsible for any injury or loss

that may occur while you are on board any airplane, bus, boat or other carrier provided by

Transformed Holy Land Tours, LLC under this Tour Agreement.

18. Release of Liability for Loss or Injury Resulting from Ordinary Negligence. Except for gross

negligence or intentional wrongdoing of Transformed Holy Land Tours, LLC, its direct employees,

agents or tour hosts, Transformed Holy Land Tours, LLC assumes no liability or responsibility for any

loss, injury, inconvenience, illness, or damage of any kind (including general and consequential

damages) occasioned by the ordinary negligence of such persons or by other circumstances and

risks outside of their control.

19. Liquidated Damages for Breach of Tour Agreement. In no event will Transformed Holy Land

Tours, LLC, its agents or tour hosts, be liable for loss of profits or any special, incidental, or

consequential damages, however caused, even if Transformed Holy Land Tours, LLC has been advised

of the possibility of such damages. Any action arising under this Tour Agreement or because of its

breach must be commenced within one year after the cause of action accrues. From the nature of

the services to be provided by Transformed Holy Land Tours, LLC, it is impracticable and extremely

difficult to fix the actual damages, if any, that you may incur as a result of Transformed Holy Land

Tours, LLC failure to perform any of its obligations under this Agreement. Accordingly, if

Transformed Holy Land Tours, LLC is found liable for loss or damage arising from breach of this

Agreement, its liability will be limited to the refund to you of an amount equal to the total amount

you paid for the tour as liquidated damages and not as a penalty; and this remedy shall be exclusive.

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20. Modified Travel. All passengers shall travel with the tour group, except as pre-arranged by the

host. Passenger originations may vary, but all passengers must travel together from the tour

departure point in the USA and back to the USA together.

21. Payment Plan. All cancellation provisions apply if this option is chosen.

22. Children. Must be accompanied by a parent, legal guardian or temporary custodian. The parent or

legal guardian must sign release of liability forms and give permission to a temporary custodian

along with permission to seek medical attention, if necessary.

23. Dress. Modesty and appropriateness are essential. Comfortable travel shoes and attire is important. Women should bring a head covering (scarf or hat). They shall not wear clothing that exposes their shoulders or is low cut. All women’s clothing should cover to the top of the knees. Men may not wear shorts or shirts that expose their shoulders. Men should remove hats before entering any of the holy sites. No traveler shall wear clothing that has sayings that might be questionable or offensive to Israel’s multi-cultural residents. Travelers may want to include one business casual type outfit. It is warm in March – somewhat like May in the Southern USA. It is wise to pack a light piece of outwear with a hood. If the traveler is sun sensitive, s/he should include a hat and wear sunscreen. Please do not wear expensive jewelry or any item that draws attention to yourself.

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Registration form

Please complete this form, or a copy, and mail it along with the registration fee to Transformed Holy

Land Tours, LLC, 6440 Hampton Highlands Drive, Cumming, GA 30041. The form may also be

submitted to the Office of the Pastor, Highland Baptist Church, Florence, AL located at 219

Simpson Street, Florence, Alabama 35630. All registration forms must be accompanied with a

$300.00 non-refundable deposit. Please make check payable to Transformed Holy Land Tours, LLC.

Please see brochure for trip details, including what is included and what is not included in your

trip payment. Payments are by check or money order only. No credit cards.

Please complete the following information. One form per passenger.

Check all that apply:

Double Occupancy or Single Occupancy (Additional $750.00)

Non-refundable registration Fee of $300.00 due at the time of registration.

Lump sum payment $3650 after registration fee is payed. Due no later than December 1, 2017.

Monthly Payment Plan, interest free available for those who register before July 31, 2016. ($300.00 non-refundable deposit due at time of registration.) The balance of $3,6500.00 is payable in eight (8) payments of $456.25/each. Payments, after the first payment with the registration fee, are due on the first working day of each month, beginning July 1, 2016 and ending on January 1, 2017.

Costs not included in the tour package are described in the Brochure.

Payment can be made by check or money order to Transformed Holy Land Tours, LLC. Returned checks

charges are $50.00, in addition to any bank charges.

Name as on Passport:

Passport Number: Expiration Date:

Note: Passport must have six (6) or more months left, after March 30, 2017, until expiration in order to be valid for this trip.

Name as preferred on Nametag:

Mailing Address:

City: State: Zip Code:

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Physical Address:

(if different from the mailing address)

City: State: Zip Code:

Home Phone: Cell Phone

E-mail Address:

Sex: Male Female Date of Birth*

*Required for international travel.

Is the passenger 18 years of age or older? Yes No. If no, please state age of the passenger.

If no, is the passenger’s parent or legal guardian a registered passenger on the Tour? Yes No.

If No, please provide the name of the child’s custodian and contact information?

Frequent Traveler Program Numbers:

United or Star Alliance FF #:

Roommate during the Tour is:

Signature (Required for each passenger)

I have read in its entirety the Brochure and the Tour Conditions and Agreement, including all information about refunds, cancellations, risks and release from liability. I agree to all of the terms and conditions set forth herein.

Signed: Date:

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Administrative Use Only

Contract Number: Date Received: Deposit Payment, Check or Money Order Number: (Copy form of payment and attach to Registration Form) Date Reservation was Faxed to VIP Travel: Date of payment to VIP Travel: Payments: Non-refundable Deposit of $300

Date Received Received by

Lump Sum balance of $3650.00

Date Received Received by

Monthly payments of $456.25: (Available to those who register before July 31, 2016) June w/registration. Date Received Received by July 1, 2016. Date Received Received by If registered in July, must make up June payment and pay July fee. No payment plan registrants after July 31. August 1, 2016. Date Received Received by September 1, 2016. Date Received Received by October 1, 2016. Date Received Received by November 1, 2016. Date Received Received by December 1, 2013. Date Received Received by January 1, 2017. Date Received Received by Total Paid: $3,950.00 Date: Initials