SCHEDULE FORM OF STATEMENT

SCHEDULE FORM OF STATEMENT

(A Statement in this form, or in a form to the like effect, must be completed and forwarded to Licensing, Surrey Heath Borough Council, within ONE MONTH of the date of the collection)
Form of Account of Proceeds, Expenses and Application of Proceeds

(All amounts to be entered GROSS)
Name of the person to whom the permit was granted: *

First NameLast Name
Address of the person to whom the permit was granted:*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Street Collection Permit Number
Name of the charity or fund which is to benefit:*
Date of Collection*

MonthDayYear

Proceeds of Collection:*

Expenses and Application of Proceeds*

	Amount	Total
Printing & Stationery
Postage
Advertising
Collecting Boxes
Badges
Emblems
Other Items
Payments approved under Regulation 16(2)
Disposal of Balance

Please provide details of 'Other Items' (if applicable)
Please provide Disposal of Balance Particulars
Certificate of Promoter
I certify that to the best of my knowledge and belief the above is a true account of the proceeds, expenses and application of the proceeds of the collection.*

Tick to confirm
Date*

MonthDayYear
Email address of Promoter*
example@example.com

Certificate of Accountant / Independent Responsible Person
Please provide details of your Accountant or Independant Responsible Person who we can contact for confirmation that the above is in their opinion a true account of the proceeds, expenses and application of the proceeds of the collection to which it relates.
Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Privacy Statement

Details of Surrey Heath Borough Council’s Privacy Notice can be found here
Should be Empty:

Form of Account of Proceeds, Expenses and Application of Proceeds