Postal Address: Licensing Department, South Hams District Council, Follaton House, Plymouth Road, Totnes, Devon, TQ9 5NE Email: Permit / Collection Details Name and Address of the person to whom the permit was granted Name of Charity or Fund, which is to benefit Date(s) of collection Permit Number Proceeds of Collection Amount Total Expenses and Application of Proceeds Amount Total From Street Collection Printing and Stationery From Other Sources Postages Bank Interest Collection boxes and carriage Other Items: Badges or any other adornments Other items (if any) Payment 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. Print Name Signature Dated Certificate of Accountant or other responsible person I certify that I have obtained all the information and explanations required of me and that the above is in my opinion a true account of the proceeds, expenses and application of the proceeds of the collection Print Name Signature Dated
Postal Address: Licensing Department, South Hams District Council, Follaton House, Plymouth Road, Totnes, Devon, TQ9 5NE Email: Permit / Collection Details Name and Address of the person to whom the permit was granted Name of Charity or Fund, which is to benefit Date(s) of collection Permit Number Proceeds of Collection Amount Total Expenses and Application of Proceeds Amount Total From Street Collection From Other Sources Bank Interest Other Items: Printing and Stationery Postages Collection boxes and carriage Badges or any other adornments Other items (if any) Payment 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. Print Name Signature Dated Certificate of Accountant or other responsible person I certify that I have obtained all the information and explanations required of me and that the above is in my opinion a true account of the proceeds, expenses and application of the proceeds of the collection Print Name Signature Dated
SH_Form_of_Statement_2017.docx