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FORM 72H STATEMENT OF MONIES RECEIVED

THE QUEEN'S BENCH Centre

[Title of Proceeding]

MONIES RECEIVED

Amount

Date rec'd.

From whom rec'd.

Explanation

Amount received as income

Amount received as capital

[List monies received in chronological order of receipt.]

Sub-totals:

TOTAL AMOUNT OF MONIES RECEIVED:

Form 72H (page 1 of 1) 09/08

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