With Heart Foundation

Section 15(2)
Collections for Charitable Purposes Act 1939

CHARITY

Name of Licensee:
Licence Number:
Statement Period:	to
Contact Name:
Address:
Telephone:

	(A) $	(B) $	Available for Charitable Purposes (A) - (B) $	(C) Amount distributed for charitable purposes in the financial year $
Section 6 Licence
Section 7 Licence
Additional information (if required) (D)

(A)	Money collected pursuant to Section 6 licence include: direct mail, telemarketing, general unsolicited donations, internet donations, badge/flower/token days, door knock appeals, payroll deduction schemes, donations in memoriam and bequests (only note bequests if monies have been received), grants. If property is collected or received for a charitable purpose (e.g. clothing, second hand goods etc.), the money received from the sale of the property must be included in (A). Money collected pursuant to Section 7 for the Charge of admission (i.e. entertainments) include: dinners/balls, quiz nights and film nights.
(B)	Costs associated with the collection or receipt of money include the relevant proportion of any fixed or overhead costs. (Do not include any other running cost of the charity).
(C)	Declaration of the amount of the gross proceeds distributed for charitable purposes in the financial year. If any disparities are shown between the amount available for the charitable purposes and the amount distributed for charitable purposes, provide reasons in D.
(D)	If payment has been made to speaker or other performer at any entertainment that exceeds $5,000, this information must be detailed.

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