## **Trustees' Annual Report for the period**
## **From**
Period start date Period end date
## **To**
08 09 2021
31 12 2022
Section A Reference and administration details
**TAR**
December 2022
1
## **Charity name**
1001Fontaines UK
**Other names charity is known by**
**Registered charity number (if any)**
1195738
**Charity's principal address**
Hamilton House
**TAR**
December 2022
2
## Mabledon Place
Bloomsbury - London
## **Postcode**
## **WC1H 9BB**
## **Names of the charity trustees who manage the charity**
**Trustee name Office (if any) Dates acted if not for whole year Name of person (or body) entitled to appoint trustee (if any)**
**TAR**
December 2022
3
1
2
Rosemary O’Mahony Chair
Yes
Lynn Maxwell Treasurer
Yes
3
Gaelle Drory-Liaudet
Yes
4
Stephen Harvey
Yes
5
Jasmine Dhiman
**TAR**
December 2022
4
26/09/2022 Yes
6
7
8
## Julien Ancele
Yes
9
**TAR**
December 2022
5
io
li
12
13
14
TAR
December 2022
15
16
17
18
TAR
December 2022
19
20
## **Names of the trustees for the charity, if any, (for example, any custodian trustees)**
**Name Dates acted if not for whole year**
**TAR**
December 2022
8
## **Names and addresses of advisers (Optional information)**
## **Type of adviser Name Address**
## **Name of chief executive or names of senior staff members (Optional information)**
## **Section B Structure, governance and management**
**TAR**
December 2022
9
**Description of the charity’s trusts**
Type of governing document (eg. trust deed, constitution)
Constitution
How the charity is constituted
(eg. trust, association, company)
Charitable Incorporated Organisation (foundation structure)
Trustee selection methods
(eg. appointed by, elected by)
Appointed by the Board of Trustees
## **Additional governance issues (Optional information)**
You **may choose** to include additional information, where relevant, about:
- policies and procedures adopted for the induction and training of trustees;
- the charity’s organisational structure and any wider network with which the charity works;
- relationship with any related parties;
- trustees’ consideration of major risks and the system and procedures to manage them.
## **Section C Objectives and activities**
## **Summary of the objects of the charity set out in its governing document**
To relieve poverty, sickness, and poor health of the public, and to protect the health of the public.
It is currently envisaged that the charity will provide assistance in areas including but not limited to Cambodia, Myanmar, Madagascar and Vietnam.
## **Summary of the main activities undertaken for the public benefit in relation to these objects (include within this section the statutory declaration that trustees have had regard to the guidance issued by the Charity Commission on public benefit)**
(I) providing and improving safe drinking water supplies in areas of the world where it is needed (and particularly in remote or isolated communities);
(II) providing education in such areas of the world in relation to the importance of safe drinking water, particularly in respect of health and hygiene; and
(III) providing support and education in such areas of the world in relation to the development, maintenance and sustainability of supplies of safe drinking water.
## **Additional details of objectives and activities (Optional information)**
You **may choose** to include further statements, where relevant, about:
- policy on grantmaking;
- policy programme related investment;
- contribution made by volunteers.
- The charity achieves its aims through:
**TAR**
December 2022
10
(I) raising funds from various sources (which may include, but shall not be limited to, receiving donations, grants and governmental aid);
(II) forming partnerships with companies, foundations, institutional bodies and NonGovernmental Organisations each of whom contribute to the development of the countries concerned;
(III) utilizing the funds raised by conducting the following activities, in partnership with the local NGO partners:
- providing and improving safe drinking water supplies in areas of the world where it is needed (and particularly in remote or isolated communities;
- providing education in such areas of the world in relation to the importance of safe drinking water, particularly in respect of health and hygiene
- providing support and education in such areas of the world in relation to the development, maintenance and sustainability of supplies of safe drinking water; and
- contributing to the research and development of any new solutions which the partnerships intend to deploy (or assist in deploying).
The CIO comprises a small base in the UK and operates as a global network of support by contributing all of the funds which it raises (less any costs of the organisation) to the local NGO partners, all of which aim at increasing the availability, and awareness of the importance of, safe drinking water in remote parts of the world.
## Section D Achievements and performance
**TAR**
December 2022
11
Section D Achievements and performance
**Summary of the main achievements of the charity during the year**
In its first year, 1001fontaines UK undertook the following activities:
- **Development of UK partnerships:** we raised funds from various sources from the UK by forming partnerships with companies and foundations
- **Participation at the Thames Path Challenge** in September 2022 with more than 50 participants – individuals and corporates. This event was used to raise funds and awareness for 1001fontaines UK
- **Advocacy workshop evening in collaboration with WaterAid** and Belu Water for World Water Day on March 22th 2022 at The Conduit in London to inform partners, donors and WASH stakeholders about 1001fontaines’ actions with respect to climate change
These activities contributed to raising awareness and fundraising a total of £73,100.
## **Section E Financial review**
**TAR**
December 2022
12
## **Brief statement of the charity’s policy on reserves**
1001fontaines UK has several internal rules and process, in line with 1001fontaines’ global policy:
- The trustees have to approve the UK annual budget.
- - Allocation of unrestricted funds discussed during our quarterly board meetings.
- - Every expense over £2,000, whether unrestricted funds or not, has to be approved in writing both by the Chair and Treasurer.
- We have 6 months of treasury secured.
## **Details of any funds materially in deficit**
## **Further financial review details (Optional information)**
1001fontaines UK’s principal sources of funds have been You **may choose** to include donations. additional information, where relevant about:
- the charity’s principal sources of funds (including any fundraising);
- how expenditure has supported the key objectives of the charity;
- investment policy and objectives including any ethical investment policy adopted.
## **Section G Declaration**
## **The trustees declare that they have approved the trustees’ report above.**
**Signed on behalf of the charity’s trustees**
**Signature(s)**
**TAR**
December 2022
13
**Full name(s)**
## Lynn Maxwell
**Position (eg Secretary, Chair, etc)**
## Treasurer
## **Date**
**TAR**
December 2022
14
**No (if any) 1001fontaines UK 1195738 Receipts and payments accounts For the period** Period start date Period end date **To from** 08.09.21 31.12.22
|**Section A Receipts and payments**|**Section A Receipts and payments**|**Section A Receipts and payments**||||||
|---|---|---|---|---|---|---|---|
|**A1 Receipts**|**Unrestricted**
**funds**
**to the nearest £**||**Restricted funds**
**to the nearest £**||**Endowment**
**funds**
**to the nearest £**||**Total funds**
**to the nearest £**
**31'861**
**-**
**-**
**2'062**
**-**
**39'177**
**-**
**-**
**73'100**
**-**
**-**
**-**
**73'100**
**5'577**
**-**
**47'000**
**-**
**-**
**-**
**-**
**-**
**-**
**52'577**
**-**
**-**
**-**
**52'577**
**20'523**
**-**
**-**
**20'523**|
|
VoluntaryIncome(donations &gifts)|**31'861**||**-**||**-**||**31'861**|
|Income Generation|**-**||**-**||**-**||**-**|
|Investment Income|**-**||**-**||**-**||**-**|
|Charitable Activities|**2'062**||**-**||**-**||**2'062**|
|Advance Receipts|**-**||**-**||**-**||**-**|
|1001fontaines France subvention|**39'177**||**-**||**-**||**39'177**|
||**-**||**-**||**-**||**-**|
||**-**||**-**||**-**||**-**|
|**_Sub total_**_(Gross income for AR)_|**73'100**||**-**||**-**||**73'100**|
|||||||||
|**A2 Asset and investment sales,**
**(see table).**||||||||
||**-**|||||||
||**-**|||||||
|**_Sub total_**|**-**|||||||
|**_Total receipts_**
**A3 Payments**||||||||
|
Cost of Generating funds (marketing &
admin))|**5'577**||**-**||**-**||**5'577**|
|Grantmaking|**-**||**-**||**-**||**-**|
|Support Costs|**47'000**||**-**||**-**||**47'000**|
||**-**||**-**||**-**||**-**|
||**-**||**-**||**-**||**-**|
||**-**||**-**||**-**||**-**|
||**-**||**-**||**-**||**-**|
||**-**||**-**||**-**||**-**|
||**-**||**-**||**-**||**-**|
|**_Sub total_ **|**52'577**||**-**||**-**||**52'577**|
|||||||||
|**A4 Asset and investment**
**purchases, (see table)**||||||||
||**-**|||||||
||**-**|||||||
|**_Sub total_ **|**-**|||||||
|**_Total payments_**
**_Net of receipts/(payments)_**
**A5 Transfers between funds**
**A6 Cash funds last year end**
**_Cash funds this year end_**||||||||
||**20'523**||||||**20'523**|
||**-**||||||**-**|
||**-**||||||**-**|
||**20'523**||||||**20'523**|
CCXX R1 accounts (SS)
1
23.03.23
## **Section B Statement of assets and liabilities at the end of the period**
|**Categories**
**B1 Cash funds**
**B2 Other monetary assets**|Wise Transfer
**Details**
**Details**
**_Total cash funds_**
(agree balances with receipts and payments account(s))|**Unrestricted**
**funds**
**to nearest £**
**20'523**
**Agreement Error**
**-**
**20'523**
OK
**Unrestricted**
**funds**
**to nearest £**
**-**
**-**
**-**
**-**
**-**
**-**|**Restricted funds**
**to nearest £**|
|---|---|---|---|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||OK|
||||**Restricted funds**
**to nearest £**|
|||**-**|**-**|
|||**-**|**-**|
|||**-**|**-**|
|||**-**|**-**|
|||**-**|**-**|
|||**-**|**-**|
|**B4 Assets retained for the**
**charity’s own use**
**B5 Liabilities**
**B3 Investment assets**|**Details**
**Details**
**Details**|**Fund to which asset**
**belongs**
**Fund to which asset**
**belongs**
**Fund to which**
**liability relates**|**Cost (optional)**|
|---|---|---|---|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**Cost (optional)**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**Amount due**
**(optional)**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
||||**-**|
Signed by one or two trustees on behalf of all the trustees
Signature
Print Name
CCXX R2 accounts (SS)
2
23.03.23
**----- Start of picture text -----**
CC16a
**----- End of picture text -----**
## **Last year**
**to the nearest £ - - - - - - - - -**
**-**
**-**
**-**
CCXX R3 accounts (SS)
3
23.03.23
**----- Start of picture text -----**
Endowment
funds
to nearest £
**----- End of picture text -----**
OK **Endowment funds to nearest £**
**-**
**Current value (optional) - - - - -**
**Current value (optional) - - - - - - - - -**
**When due (optional)**
Date of approval
CCXX R4 accounts (SS)
23.03.23
4
## CALDER & CO
## CHARTERED ACCOUNTANTS
**----- Start of picture text -----**
PARTNERS
**----- End of picture text -----**
P K S EWEN D J GALLAGHER I ROSMARIN T BADIANI J J DAVIS A V KOUPLAND V MORJARIA **CONSULTANT:** D J LYON **CERTIFIED ASSOCIATE** : E N BAYLIS
## 30 ORANGE STREET LONDON WC2H 7HF
TEL: 020 7839 6655 FAX: 020 7839 6016 EMAIL: info@calders.net www.calders.net
Our Ref: F167V/HM
9 March 2023
Dear Chrystèle,
## 1001FONTAINES UK – PERIOD ENDED 31 DECEMBER 2022
Following the conclusion of our Independent Examination, I enclose the following documents for your attention:
1. Accounts. I enclose herewith a copy of the final accounts with our recommended changes. Once agreed at the Trustees meeting, please send back a copy of the signed accounts so that the examiner’s report can be signed.
2. Letter of Representation. Please sign and return this to me as soon as possible _._
3. Management Letter. The enclosed management letter is for your attention.
Our fee note will follow shortly.
With best wishes,
Yours sincerely,
VAISHALI MORJARIA
Ms C Jacqmarcq 1001fontaines UK Hamilton House Mabledon Place Bloomsbury London WC1H 9BB
**----- Start of picture text -----**
246311
**----- End of picture text -----**
REGISTERED TO CARRY ON AUDIT WORK IN THE UK AND REGULATED FOR A RANGE OF INVESTMENT BUSINESS ACTIVITIES BY THE INSTITUTE OF CHARTERED ACCOUNTANTS IN ENGLAND AND WALES
Accounting * Audit * Business Start Up * Compa ny Sec retarial * Due Dilige nce * Inhe rita nce Tax * Non-domic iles * Pa yroll * Personal & Corporate Tax * Tax Re turns * Trusts & Estates * VAT Calder & Co is the trading name of Calders (1883) LLP (a Limited Liability Partne rship registered in England and Wales at the above addre ss) Registered No. OC 415228
1001fontaines UK Hamilton House Mabledon Place Bloomsbury London WC1H 9BB
8 March 2023
## Dear Sirs
## **LETTER OF REPRESENTATION**
We confirm that the following representations are made on the basis of enquiries of management and staff with relevant knowledge and experience and, where appropriate, of inspection of supporting documentation, sufficient to satisfy ourselves that we can properly make each of the following representations to you, in connection with your examination charity’s receipts and payments account (the ‘account’) and a statement of assets and liabilities (the ‘statement’) as its annual statement of account for the period ended 31 December 2022.
1. We acknowledge, as trustees our collective responsibility under the Charities Act 2011 for presenting the account and statement and confirm that we have approved the account and statement for the period ended 31 December 2022. We also acknowledge our responsibility for making accurate representations to you. All the accounting records have been made available to you for the purpose of your assignment and all the transactions undertaken by the charity have been properly reflected and recorded in the accounting records. All other records and related information, including minutes of all trustee and management meetings, have been made available to you.
2. We confirm that the charity is entitled to prepare receipts and payments accounts and is eligible for an independent examination of its account and statement, and that there are no circumstances which we should draw to your attention which would invalidate this eligibility. We acknowledge that the work performed by you is substantially less in scope than an audit performed in accordance with International Standards on Auditing (UK).
3. All grants, donations and other incoming resources, the receipt of which is subject to specific terms or conditions, have been notified to you. There have been no breaches of terms or conditions during the period in the application of such incoming resources. The following endowments and restricted income grants and donations were received during the period:
4. The charity has satisfactory title to all assets and there are no liens or encumbrances on the charity’s assets except as disclosed to you.
5. We acknowledge our responsibility for the design and implementation of internal controls to prevent and detect errors or fraud and have disclosed to you the results of our assessment of the risk that the account and statement may be materially misstated as a result of fraud. We are unaware of any irregularities, including fraud and suspected fraud, involving management, employees or others who have significant roles in internal control, or those employed by the charity where the fraud could have a material effect on the financial statements. No allegations of such irregularities or breaches have come to our notice.
1001fontaines UK Charity Number: 1195738
Registered Office: Hamilton House, Mabledon Place, Bloomsbury, London WC1H 9BB
6. We are unaware of any breaches or possible breaches of statute, regulations, contracts, agreements or the charity’s constitution which might result in the charity suffering significant penalties or other loss. No allegations of such irregularities or breaches have come to our notice. We confirm that the charity has had no non-routine communication with Charity Commission during or since the period of which you are unaware.
7. We have reviewed the affairs of the charity and confirm that no income is subject to income or capital gains tax. We have also reviewed the VAT treatment in relation to contractual services provided by the charity and confirm that VAT has been correctly accounted for
8. The account and statement have been prepared on the going concern basis as we believe that adequate cash resources will be available to cover the charity’s requirements for working capital and capital expenditure for at least the next twelve months. We are not aware of any other factors which could put into jeopardy the charity’s going concern status during or beyond this period.
Yours faithfully
Name: Lynn Maxwell
Signed on behalf of the board of trustees 1001fontaines UK
Calder & Co 30 Orange Street London WC2H 7HF
1001fontaines UK Charity Number: 1195738
Registered Office: Hamilton House, Mabledon Place, Bloomsbury, London WC1H 9BB
## CALDER & CO
## CHARTERED ACCOUNTANTS
## **PARTNERS**
P K S EWEN D J GALLAGHER I ROSMARIN T BADIANI J J DAVIS A V KOUPLAND V MORJARIA **CONSULTANT:** D J LYON **CERTIFIED ASSOCIATE** : E N BAYLIS
## 30 ORANGE STREET
LONDON WC2H 7HF
TEL: 020 7839 6655 FAX: 020 7839 6016 EMAIL: info@calders.net www.calders.net
## Our Ref: F167V/HM
## 8 March 2023
Dear Sirs,
## MANAGEMENT LETTER PERIOD ENDING 31 DECMBER 2022
## Introduction
Following our recent independent examination in connection with the financial statements of 1001fontaines UK for the period ending 31 December 2022, we are writing to bring to your attention certain matters that arose during the course of our work.
Our work included an examination of some of the charity’s transactions, procedures and controls. This work was not directed primarily towards discovering weaknesses or towards the detection of fraud. We have included in this letter only matters that have come to our attention as a result of our normal procedures and consequently our comments should not be regarded as a comprehensive record of all weaknesses that may exist or of all improvements that might be made.
## Breaches of duty imposed by law and regulation
During the course of our review we discovered no breaches of duty relevant to the administration of the charity imposed by any enactment or rule of law on the trustees, managers or any professional advisors, regardless of whether such matters gave rise to a statutory duty to report to The Charity Commission.
Cont’d/…2
246317
REGISTERED TO CARRY ON AUDIT WORK IN THE UK AND REGULATED FOR A RANGE OF INVESTMENT BUSINESS ACTIVITIES BY THE INSTITUTE OF CHARTERED ACCOUNTANTS IN ENGLAND AND WALES
Accounting * Audit * Business Start Up * Compa ny Sec retarial * Due Dilige nce * Inhe rita nce Tax * Non-domic iles * Pa yroll * Personal & Corporate Tax * Tax Re turns * Trusts & Estates * VAT Calder & Co is the trading name of Calders (1883) LLP (a Limited Liability Partne rship registered in England and Wales at the above addre ss) Registered No. OC 415228
-2-
## Significant difficulties encountered during the independent examination
During the course of our review we encountered no significant difficulties.
## Internal controls
We recognise that the number of your accounting staff makes a complete system of internal control impracticable. We also recognise that the trustees exercise diligent oversight. We have taken the foregoing into account in conducting our examination and in preparing this letter.
## Summary
There were no important matters that arose as a result of our work.
## Conclusion
If you require any further information or assistance, we shall be very pleased to help you.
We would appreciate an acknowledgement of the receipt of this letter.
This letter is for your private use only. It has been prepared on the understanding that it will not be disclosed to any third party, or quoted to or referred to, without our prior written consent and we assume no responsibility to any other party.
We should like to take this opportunity of thanking Chrystèle Jacqmarcq for the assistance and co-operation we have received during the course of our work.
Yours faithfully,
CALDER & CO
1001fontaines UK Hamilton House Mabledon Place Bloomsbury London WC1H 9BB
REGISTERED TO CARRY ON AUDIT WORK IN THE UK AND REGULATED FOR A RANGE OF INVESTMENT BUSINESS ACTIVITIES BY THE INSTITUTE OF CHARTERED ACCOUNTANTS IN ENGLAND AND WALES
246317
Accounting * Audit * Business Start Up * Compa ny Sec retarial * Due Dilige nce * Inhe rita nce Tax * Non-domic iles * Pa yroll * Personal & Corporate Tax * Tax Re turns * Trusts & Estates * VAT Calder & Co is the trading name of Calders (1883) LLP (a Limited Liability Partne rship registered in England and Wales at the above addre ss) Registered No. OC 415228
## **INDEPENDENT EXAMINER’S UNQUALIFIED REPORT**
## **1001fontaines UK**
## **Independent Examiner’s Report to the Trustees of 1001fontaines UK**
I report to the trustees on my examination of the accounts of 1001fontaines UK (‘the charity’) for the period ended 31 December 2022 which comprise the summary of receipts and payments as stated in Appendix 1.
This report is made solely to the charity’s trustees, as a body, in accordance with section 145 of the Charities Act 2011. My work has been undertaken so that I might state to the charity’s trustees those matters I am required to state to them in this report and for no other purpose. To the fullest extent permitted by law, I do not accept or assume responsibility to anyone other than the charity and the charity’s trustees as a body, for my work, for this report, or for the opinions I have formed.
## **Responsibilities and basis of report**
As the trustees of the charity, you are responsible for the preparation of the accounts in accordance with the requirements of the Charities Act 2011 (‘the Act’).
I report in respect of my examination of the charity’s accounts carried out under section 145 of the Act and in carrying out my examination I have followed all the applicable Directions given by the Charity Commission under section 145(5)(b) of the Act.
An independent examination does not involve gathering all the evidence that would be required in an audit and consequently does not cover all the matters that an auditor considers in giving their opinion on the accounts. The planning and conduct of an audit go beyond the limited assurance that an independent examination can provide. Consequently, I express no audit opinion on the accounts and my report is limited to those specific matters set out in the independent examiner’s statement.
## **Independent examiner’s statement**
I have completed my examination. I confirm that no material matters have come to my attention in connection with the examination giving me cause to believe that in any material respect:
- ➢ accounting records were not kept in respect of the charity as required by section 130 of the Act; or
- ➢ the accounts do not accord with those records.
I have no concerns and have come across no other matters in connection with the examination to which attention should be drawn in this report to enable a proper understanding of the accounts to be reached.
Vaishali Morjaria ACA Calder & Co 30 Orange Street London WC2H 7HF Date:
Appendix 1: 1001fontaines UK Accounts - receipts and payments
**----- Start of picture text -----**
No (if any)
1001fontaines UK 1195738
Receipts and payments accounts CC16a
For the period Period start date Period end date
To
from 08/09/2021 31/12/2022
Section A Receipts and payments
Unrestricted Restricted Endowment
Total funds Last year
funds funds funds
to the nearest £ to the nearest £ to the nearest £ to the nearest £ to the nearest £
A1 Receipts
Voluntary Income (donations & gifts) 31,861 - - 31,861 -
Income Generation - - - - -
Investment Income - - - - -
Charitable Activities 2,062 - - 2,062 -
Advance Receipts - - - - -
1001fontaines France subvention 39,177 - - 39,177 -
- - - - -
- - - - -
Sub total (Gross income for
73,100 - - 73,100 -
AR)
A2 Asset and investment sales,
(see table).
- - - -
- - - - -
Sub total - - - - -
Total receipts 73,100 - - 73,100 -
A3 Payments
Cost of Generating funds (marketing &
admin)) 5,577 - - 5,577 -
Grantmaking - - - - -
Support Costs (wages) 47,000 - - 47,000 -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
Sub total [ 52,577 ] - - 52,577 -
A4 Asset and investment
purchases, (see table)
- - - -
- - - -
Sub total [ - ] - - - -
Total payments 52,577 - - 52,577 -
Net of receipts/(payments) 20,523 - - 20,523 -
A5 Transfers between funds - - - - -
A6 Cash funds last year end - - - - -
Cash funds this year end 20,523 - - 20,523 -
**----- End of picture text -----**
Appendix 1: 1001fontaines UK Accounts - receipts and payments
|**Section B Statement of assets and liabilities at**|**Section B Statement of assets and liabilities at**|**the end of the period**|**the end of the period**||
|---|---|---|---|---|
|**Categories**
Signed by one or two trustees on
behalf of all the trustees
**B5 Liabilities**
**B3 Investment assets**
**B2 Other monetary assets**
**B4 Assets retained for the**
**charity’s own use**
**B1 Cash funds**|**Details**
**Details**
**_Total cash funds_**
(agree balances with receipts and payments
account(s))
Wise Account GBP
**Details**
**Details**
**Details**
Signature|**Unrestricted**
**funds**
**to nearest £**
**20,523**
**-**
**-**
**20,523**
OK
**Unrestricted**
**funds**
**to nearest £**
**-**
**-**
**-**
**-**
**-**
**-**
**Fund to which**
**asset belongs**
**Fund to which**
**asset belongs**
**Fund to which**
**liability relates**|**Restricted**
**funds**
**to nearest £**
**-**
**-**
**-**
**-**
OK
**Restricted**
**funds**
**to nearest £**
**-**
**-**
**-**
**-**
**-**
**-**
**Cost (optional)**
**-**
**-**
**-**
**-**
**-**
**Cost (optional)**
**-**
**-**
**-**
**-**
**-**
**-**
**-**
**-**
**-**
**Amount due**
**(optional)**|**Endowment**
**funds**
**to nearest £**
**-**
**-**
**-**|
|||||**-**|
|||||OK|
|||||**Endowment**
**funds**
**to nearest £**
**-**
**-**
**-**
**-**
**-**
**-**
**Current value**
**(optional)**
**-**
**-**
**-**
**-**
**-**
**Current value**
**(optional)**
**-**
**-**
**-**
**-**
**-**
**-**
**-**
**-**
**-**
**When due**
**(optional)**|
||||**-**
**-**
**-**
**-**
**-**||
|||Print Name
Lynn Maxwell||Date of
approval|