REGISTER OF HARM PREVENTION CHARITIES (the Register)

ANNUAL STATISTICAL RETURN OF TAX DEDUCTIBLE DONATIONS

Financial Year ending in 2011

The audited financial statement for the institution and its public fund must be attached to this form

PART A – INSTITUTION & PUBLIC FUND DETAILS

Please state the institution’s financial year:  _____________________________________

Full Name of Charitable Institution: 							

Australian Business Number: __  __  __  __  __  __  __  __  __  __  __

Postal Address: 										

Telephone: 					   Fax: 						

Email Address: 										

Internet Address: 										

Name of Public Fund: 									

Principal Harm Prevention Activity/ies :							

Public Fund Management Committee Members: (if insufficient space, attach list)
Responsible person category - see Register’s Guidelines (paragraph 1.9)	Full Name	Date of Appointment	

			

PART B – PUBLIC FUND DONATIONS

Harm prevention charities listed on the Register must actively seek donations of money or property from the community in order to maintain their tax deductibility status.

Donations are gifts made unconditionally.  Therefore, corporate sponsorships are not gifts, and sponsorship monies must not be placed in the public fund account.

Donations to your Public Fund (Financial year ending 2011)

Donation*	Number of Donations	Donation Amount	
Money $2 or more		$	
Property >$5,000		$	
Property <12 months		$	
Trading stock		$	
TOTAL		$	

* For a detailed description of these gift types please refer to the Australian Taxation Office website http://www.ato.gov.au/nonprofit/content.asp?doc=/content/61197.htm

B1. 	How did you actively seek donations in the financial year ending 2011? 
Please describe.

	

	

B2. 	Were any donations received on an unsolicited basis?
No – Go to Question B3
Yes – Please describe

	

	

B3. 	As well as tax deductible donations, did you receive donations of amounts less than $2 and non tax deductible donations? Please describe.

How much?	How many?	Total?	Describe	

				

B4. 	Projected Fundraising Statement

Please provide an estimated amount, as a total budget, your institution expects to raise over the next three years as a Public Fund on the Harm Prevention Charities Register.

	Financial year ending 2012	Financial year ending 2013	Financial year ending 2014	
Government grants
				
Donations from individuals				
Donations from businesses and philanthropic organisations				
Income from other sources				
Total

PART C - EXPENDITURE OF PUBLIC FUND MONIES (Financial year ending 2011)

How did you spend your public fund donations in the financial year ending 2011 and what were the outcomes you achieved?  For example, 

Description of Expenditure on Harm Prevention Activities, including outcomes achieved	$ Value	
Project harm prevention ($50 venue hire, $50 guest presenter, $75 advertising, $25 morning tea)
Outcome – informed key stakeholders about harm prevention, stakeholders will promote harm prevention to key areas.  Project advertising and outline is attached.	$200.00	
Harm Prevention program ($100 salaries, $20 staff on cost, $50 travel, $100 operating costs)
Outcome – participants will take the skills learnt and enable them to have improved social participation in their home and community.  Program outline and objectives are attached.	$270.00	
General promotional material throughout year ($100 TV promotion, $50 radio promotion, $50 internet site, $20 letterbox drops, $20 newspaper ads)
Outcome – the general community is exposed to and has informative material available about harm prevention.  Sample newspaper ad is attached.	$240.00	

Description of Expenditure on Harm Prevention Activities, including outcomes achieved	$ Value	

		

		
		
TOTAL	$	

PART D - CHECKLIST

1. It is mandatory that you provide audited annual financial statements.
Have you enclosed audited financial statements for your institution and for your public fund for the financial year of this return? 
Yes 		No	
The financial statements should provide information on the expenditure of public fund monies and the management of public fund assets.

2. Structure of the audited annual financial statements.
Are your public fund audited financial statements included in or separate to your institution’s audited financial statement?
Included 		Separate	

3. Have you amended your constitutional documents since 30 June 2010?
Yes 		No	
If yes, please attach a copy unless it has already been provided to the Department of Families, Housing, Community Services and Indigenous Affairs.
4. Has there been any change to the management committee of the public fund since 30 June 2010?
Yes 		No	
If yes, please attach a Public Fund Management Committee Member Nomination Form for each new member and a new list of all committee members unless previously provided to the Department of Families, Housing, Community Services and Indigenous Affairs.
5. Has there been any other changes to your institution or public fund?

Yes 		No	
If yes, please describe the changes and attach any relevant documentation.

PART E - PARTICULARS OF AUDITOR

•	An audited financial statement for the institution and its public fund must be provided with this form.  The statement is to provide information on the expenditure of public fund monies and the management of public fund assets (ministerial rule 1).

•	The audited financial statement for the institution and its public fund can be in the form of one statement for both the institution and its public fund or in the form of two separate statements: one for the institution and one for the public fund.

•	The format of the annual audited financial statement should clearly identify information regarding public fund donations and public fund expenditure.  

o	Public Fund information should be marked as Public Fund
o	Donations should be marked as Public Fund or Other and should identify the type of donation.

•	The auditor’s signature below confirms the auditor has complied with items in Part E of this return and has sighted public fund information in Part B of this return regarding public fund donations and public fund expenditure.

Auditors full name: _______________________________________________________

Auditor’s signature: _______________________________________________________

Date of signature: _________________________________________________________

PART F - DECLARATION BY AUTHORISED OFFICER

I certify that to the best of my knowledge the information provided in this return is true and accurate.

Signed  											

Name 												

Position  							 Date 		/	 /	

This form must be returned no later than 4 months after the end of the institution’s 2011 financial year

Return completed form with supporting documentation to:

Register of Harm Prevention Charities
Community Investment Branch CE2
Department of Families, Housing, Community Services and Indigenous Affairs
Box 7576 Canberra Business Centre ACT 2610

For further information and other inquiries contact:

Register of Harm Prevention Charities
Ph: 1800 441 242
Email: harmpreventioncharitiesregister@fahcsia.gov.au
Website: http://www.fahcsia.gov.au/internet/facsinternet.nsf/aboutfacs/harm_nav.htm