REGISTER OF HARM PREVENTION CHARITIES (the Register)
ANNUAL STATISTICAL RETURN OF TAX DEDUCTIBLE DONATIONS
Financial Year ending in 2012
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
Full Name
category - see Register’s
Guidelines (paragraph 1.9)
Financial year ending 2012 statistical return – Register of Harm Prevention Charities
Date of
Appointment
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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 2012)
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 2012?
Please describe.
B2.
Were any donations received on an unsolicited basis?
No – Go to Question B3
Yes – Please describe
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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?
B4.
How many?
Total?
Describe
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 2013
Financial year
ending 2014
Financial year
ending 2015
Government grants
Donations from
individuals
Donations from
businesses and
philanthropic
organisations
Income from other
sources
Total
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PART C - EXPENDITURE OF PUBLIC FUND MONIES (Financial year ending 2012)
How did you spend your public fund donations in the financial year ending 2012 and what
were the outcomes you achieved? For example,
Description of Expenditure on Harm Prevention Activities,
including outcomes achieved – EXAMPLE ONLY
Project harm prevention ($50 venue hire, $50 guest presenter, $75
advertising, $25 morning tea)
$ Value
$200.00
Outcome – informed key stakeholders about harm prevention, stakeholders
will promote harm prevention to key areas. Project advertising and outline
is attached.
Harm Prevention program ($100 salaries, $20 staff on cost, $50 travel,
$100 operating costs)
$270.00
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.
General promotional material throughout year ($100 TV promotion, $50
radio promotion, $50 internet site, $20 letterbox drops, $20 newspaper ads)
$240.00
Outcome – the general community is exposed to and has informative
material available about harm prevention. Sample newspaper ad is
attached.
Description of Expenditure on Harm Prevention Activities,
including outcomes achieved
TOTAL
$ Value
$
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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 2011?
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 2011?
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.
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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:_________________________________________________________
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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 2012
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
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