FINANCIAL REPORTS TO THE DIRECTOR-GENERAL FOR A CHARITABLE COLLECTION
Charitable Collections Act 2003
Charitable Collections Regulation 2003

	
PURPOSE 

This form is to be used for the purpose of reporting to the Director-General on the collections conducted under the licence in accordance with the Charitable Collections Act 2003 (the Act).  You can access the legislation at www.legislation.act.gov.au.  You may also obtain further information and forms at www.ors.act.gov.au.
	
PRIVACY

The Act authorises the Director-General to collect the personal information required by this form for the purposes of issuing a licence under Division 4.1 of the Act.  Pursuant to Section 41 of the Act, the Director-General must keep a Register of Licenses that is available for inspection by the public. The Director-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Privacy Act 1988 (C’wlth).  The Director-General may provide additional information to law enforcement agencies and authorised organisations that have legal authority to request information under prescribed circumstances.	
CONTACT
	
Office of Regulatory Services Shopfront
255 Canberra Avenue, Fyshwick ACT 2609	Office of Regulatory Services Postal Address
GPO Box 158, Canberra ACT 2601	
Opening Hours 9:00am to 4:30pm Monday to Friday	Website www.ors.act.gov.au      Email ors.bil@act.gov.au 	
General Enquiries (02) 6207 0562	Fax Number (02) 6207 0424	
INSTRUCTIONS FOR COMPLETION 

•	Complete this form using blue or black pen only.
•	Please print; ensuring writing is clear and legible. 
•	This office will not accept lodgement of this form if it is not completed in full.
	
IMPORTANT INFORMATION
•	Applicants should be aware of their responsibilities under the Charitable Collections Act 2003.  
•	Where an individual or organisation collects less than $15,000 from ACT residents in a 12 month period a charitable collections licence is not required.  However, if you choose to hold a licence you must provide a financial report to the Director-General. 
•	Where the amount of the collection from ACT residents is less than $50,000 please complete this form, including the collection details.
•	Where the amount of the collection from ACT residents is $50,000 or more please complete this form and attach audited statements of the collection.
•	If the collection includes monies collected from other Australian States and Territories it is permissible to report on the whole collection if you are unable to distinguish between that collected from the ACT and that collected elsewhere.
•	For a licence issued for a period of 1 year or less the report must be provided within 120 days after the licence ends.
•	For a licence issued for a period longer than 1 year the report must be provided within 120 days after the end of each 12 month period until the licence ends.
	
TRANSLATING AND INTERPRETING SERVICE
If you require further information or require advice, a language assistance service is available by phoning the Translating and Interpreting Service (TIS) on 13 14 50.	

FINANCIAL REPORTS TO THE DIRECTOR-GENERAL 
FOR A CHARITABLE COLLECTION
Charitable Collections Act 2003
Charitable Collections Regulation 2003

LICENCE NUMBER
	COMMENCEMENT DATE (Office use only)	EXPIRY DATE              (Office use only)	TERM OF LICENCE     (Office use only)	

LICENCE NAME		

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 Director General 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 Director General 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 Director General within 120 days after the day the licence ends.	

COLLECTION REPORTS – please read the important information on the front page about collection	
 Audited report for collections of $50,000 or more attached                                                                                	Details (on next page) for collections of less than $50,000 provided                                                                                         	

TITLE (eg. Ms, Mr, Dr)	FULL NAME OF APPLICANT / NOMINATED PERSON 	POSITION HELD WITHIN ORGANISATION (EG. Exec Officer)	
			
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 certificaet if incorporation)	
	
AUSTRALIAN COMPANY NUMBER	AUSTRALIAN BUSINESS NUMBER	INCORPORATED ASSOCIATION	
			
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)	
	
AUDITOR’S ADDRESS	
	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	

NAME OF FINANCIAL INSTITUTION	
	
ACCOUNT NUMBER	NAME OF ACCOUNT	

COLLECTION DETAILS (for collections under $50,000)	

GROSS PROCEEDS OF COLLECTION	TOTAL EXPENSES	NETT PROCEEDS OF COLLECTIONS	
			
AMOUNT APPLIED FOR COLLECTION’S PURPOSES (please provide name of each beneficiary and amount donated)	

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.

Applicant’s name in full

Applicant’s signature                                          Date             /      /         	
Signed in my presence

Witness’ name in full

Witness’ signature                                                    Date        /      /