SCHEDULE - FORM OF STATEMENT
1	Name of the person to whom the permit was granted: ………………………………………………
2	Address of the person to whom the permit was granted: ……………………………………………
………………………………………………………………………………………………………………
Post Code: ……………………………………… Tel No: ……………...………………………………
3	Name of charity or fund which is to benefit: …………………………………………………………..
4	Date of collection: . ………………………………………………………………………………………

Show Nil Entries
Proceeds of 
Collection	
Amount	
Total	Expenses & Application of Proceeds	
Amount	
Total	

From collecting boxes

Interest on proceeds

Other items:-	£	£	
Printing & Stationery
Postage
Advertising

Collecting boxes
Badges
Emblems
Other items:-

Payments approved under Regulation 15(2)
Disposal of Balance
(insert particulars)

	£	£	
TOTAL			TOTAL

Certificate of the person to whom the permit was granted

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
.
Certificate of Accountant or Independent Responsible Person

I certify that I have obtained all the information and explanations required by me and that the above is in my opinion a true account of the proceeds, expenses and application of the proceeds of the collection.

Signed: ……………………………………………………………………………… Date: …………………….
Qualifications: …………………………………………………………………………………………………….

This application should be returned to: Kirklees Council, Licensing Department, Flint Street Depot, Flint Street, Huddersfield, HD1 6LG Tel: 01484 456868

Personal Data:

We have recently updated our Privacy Notice about how we use personal data provided to the Council. Further information can be found at:

http://www.kirklees.gov.uk/beta/information-and-data/pdf/privacy-notice-other-licenses.pdf