Isle of Wight Council

	Street Collection Return Form
	This form is used to provide information to the Council about what was collected during a permitted street collection.

Details of the person to whom the permit was granted

*	Forename
	Middlename/Initials
*	Surname

*	Building/house name/number
*	Street
*	Town
	County
*	Postcode
	Tel Number (include area code)
	Email address
	Fax

Collection details

*	Name of the charity or fund which is to benefit
*	Date of collection
*	Permit Number

	Proceeds of collection	Amount (if nil please enter 0)
*	From collection boxes (please give details on page of this form)	�
*	Interest on proceeds	�

	Other Items (please specify)		�
			�
			�
			�

*

Total

�

	Expenses and application of proceeds	Amount (if nil please enter 0)
*	Printing and stationery	�
*	Postage	�
*	Advertising	�
*	Collecting Boxes	�
*	Badges	�
*	Emblems	�

	Other Items (please specify)		�
			�
			�
			�

*	Payments approved under Regulation 15(2)	�
*	Amount donated to charity / fund	�
*	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.

	Signed ............................................................................... Name................................................................................. Date...................................................................................
	This form must be signed and presented to the licensing section before a decision is made and the licence may be granted. Either print off the completed form, sign and post to the licensing department or attend council offices to sign after you have submitted the form online.

List of amounts contained in each collection box and list of collectors

	Collecting Box Number	Amounts in Box (�s)	Full name and address of collector

	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 and complete list of the collectors and the amounts collected as required by regulations 16 (1) (b) & (c).

	Signed ............................................................................... Name................................................................................. Date...................................................................................
	This form must be signed and presented to the licensing section before a decision is made and the licence may be granted. Either print off the completed form, sign and post to the licensing department or attend council offices to sign after you have submitted the form online.

	Certificate of Account
	This Statement MUST be signed by an INDEPENDENT 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 ............................................................................... Name................................................................................. Qualification........................................................................ Date...................................................................................

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 07/03/2013