MASS REQUEST FORM

202 Stanwix Street, Pittsburgh, PA 15222

(412) 261-0110    fax (412) 261-0113

TODAY'S DATE: _______________________

PERSON REQUESTING MASSES: ________________________________________________

ADDRESS: ___________________________________________________________________

PHONE NUMBER: _______________________

DATE TIME INTENTION REQUESTED BY

_______ _______ _______________________________ ___________________

_______ _______ _______________________________ ___________________

_______ _______ _______________________________ ___________________

_______ _______ _______________________________ ___________________

_______ _______ _______________________________ ___________________

_______ _______ _______________________________ ___________________

_______ _______ _______________________________ ___________________

_______ _______ _______________________________ ___________________

_______ _______ _______________________________ ___________________

Effective January 1, 1994, in the Diocese of Pittsburgh, the approved Mass stipend is ten dollars ($10) for each Mass.