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| | PART I — PARTICULARS OF LICENSEE |
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| | Contact No. (Pager/Mobile/Home/Office) |
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| | PART II — PARTICULARS OF COLLECTION |
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| | Proceeds of Collection (amount to be entered in gross) |
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| | For collection of money only Total proceeds collected |
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| | For collection of properties sold or otherwise disposed of Amount obtained during period of account by sales of properties collected |
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| | | Breakdown of income from other sources of collection |
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| | Expenses and Application of Proceeds (amount to be entered in gross) |
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| | | Net proceeds (after deduction of expenses) distributed to the beneficiary/beneficiaries |
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| | For Collection of Property (Other Than Money) Given Away or Otherwise Disposed of |
| All properties collected in the collection of which particulars are given above have been given away/disposed of for charitable purposes in the following manner: |
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| | (1) _____________________ |
| | (2) _____________________ |
| | (3) _____________________ |
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| | (4) _____________________ |
| | (5) _____________________ |
| | (6) _____________________ |
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| | Certification by Licensee |
| I certify that to the best of my knowledge and belief the above is a true account of the expenses, proceeds and application of the proceeds of the collection to which it relates. |
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| | _____________________________ |
| | _____________________________ |
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| | I certify that I have obtained all the information and explanations required by me as an auditor and that the above is in my opinion a true account of the expenses, proceeds and application of the proceeds of the collection to which it relates. |
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| | _____________________________ |
| | _____________________________ |
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| | *Applicable to foreigners only. |
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