ACT GOVERNMENT
Charitable Collections Act 2003
Office of Regulatory Services

FR

FINANCIAL REPORTS TO THE CHIEF EXECUTIVE FOR A
CHARITABLE COLLECTION

IMPORTANT INFORMATION
Applicants should be aware of their responsibilities under the Charitable Collections Act 2003.  You can view the legislation and its regulations or download them from www.legislation.act.gov.au.  You may also obtain access to the Charitable Collections Practice Manual at and relevant forms at www.ors.act.gov.au.  This form may be used for the purposes of reporting to the Chief Executive on the collections conducted under the Licence in accordance with Section 48 of the Act.

Send completed applications to:  OFFICE OF REGULATORY SERVICES, PO BOX 225, CIVIC SQUARE, ACT 2608

LICENCE NUMBER		TERM OF LICENCE		COMMENCEMENT DATE		EXPIRY DATE	
	 Office Use only	Office Use Only	Office Use Only
     		     		     		     	

REPORTING REQUIREMENT – please identify the type of report attached to this form	
 A licence issued for a period of 1 year or less – you must report to the Chief Executive within 120 days after the day the licence ends.	
 A licence issued for a period of longer than 1 year – you must report to the Chief Executive within 120 days after the end of each 12 month period 
      for  which the licence is in force	
 A licence issued for a period of longer than 1 year – you must report to the Chief Executive within 120 days after the day the licence ends.	

AUDIT REPORTS ARE REQUIRED FOR COLLECTIONS THAT EXCEED MORE THAN $50,000 IN ANY 12 MONTH PERIOD	
 Audit report attached.	 Audit report not required	

TITLE
(eg. Ms, Mr, Dr)	FULL NAME OF CONTACT FOR LICENSEE / NOMINATED PERSON IF BODY NOT INCORPORATED	POSITION HELD WITHIN ORGANISATION 
(eg. Exec Officer)	
     	     	     	
APPLICANT ADDRESS (Property Name, Unit, Flat, Room No, Street Number, Street Name, City/Suburb/Town, Postcode)	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

NAME OF ORGANISATION – REGISTERED NAME IF INCORPORATED (if incorporated, please provide a copy of the certificate of incorporation)	
	
AUSTRALIAN COMPANY NUMBER	AUSTRALIAN BUSINESS NUMBER	INCORPORATED ASSOCIATION (if applicable)	
			
REGISTERED OFFICE ADDRESS (Property Name, Unit, Flat, Room No, Street Number, Street Name, City/Suburb/Town, Postcode)	
	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

NAME OF AUDITOR (if collection exceeds $50,000)	
     	
AUDITORS ADDRESS	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

NAME OF FINANCIAL INSTITUTION 	
     	
ACCOUNT NUMBER	NAME OF ACCOUNT	
     	     	

STATEMENT	

I, the licensee / nominated person confirm that the attached financial reports (including audited reports) are a true and accurate report on:

(i)	The proceeds of the collection (including any amounts realised from benefit received for the purpose of the collection);
(ii)	The amounts of lawful and proper expenses under the Act, section 44(3) of the collection;
(iii)	The net proceeds of the collection;
(iv)	The amount applied for the purposes of the collection.
	
LICENSEE / NOMINATED PERSON SIGNATURE 	

Applicants Name in Full

Applicant Signature                                      Dated	Signed in my presence

Witnesses Name in Full

Witness Signature                                                   Dated