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EN OF LODGE NO. A F & A M , , NEBRASKA I, amounting to $ (PRINT FULL NAME) was suspended for non-payment of dues on the day of , . I am now and desirous of being reinstated to good standing in said Lodge, and herewith make full payment of $ petition for reinstatement to membership in conformity with Nebraska Masonic Law. For this purpose, I submit the following statements of fact: I was raised to the Sublime degree of a Master Mason on the Lodge No. day of , , located in.

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