Each collection agency licensee shall, not later than January 31 of each calendar year, file with the department a verified annual statement for the preceding calendar year, showing the respective amounts of all customers' money collected by the licensee during the preceding calendar year, that has not previously been remitted to the customers entitled to it or properly accounted for, and showing also the amounts of money that the licensee has on deposit in a bank or in the licensee's possession for the purpose of liquidating any and all amounts due to customers. The statement must contain the name and address of the bank. The annual statement shall be made substantially in the following form:



ANNUAL STATEMENT TO DEPARTMENT OF COMMERCE, COMMUNITY, AND


ECONOMIC DEVELOPMENT


Pursuant to AS 08.24.210
the undersigned, ............, licensed


under AS 08.24 to conduct a collection agency business, hereby declares


that the amount of money collected during the preceding calendar year


by the undersigned, as a licensee under AS 08.24, which has not been


remitted to a customer or properly accounted for is $ ........; and


that the amount on deposit with all banks for the purpose of


liquidating all amounts to customers is $ .........


The attached schedule contains a true statement of the name and


address of each customer of the undersigned to whom there was due or


owing at the end of the preceding calendar year on account of


collections made during the preceding calendar year the aggregate sum


of $20 or more.


IN WITNESS WHEREOF, the undersigned has executed this statement


on this ..... day of ........., 2 ....


(name of licensee) .....................................


(signature) ............................................


(capacity) ................................ VERIFICATION


STATE OF ALASKA ss


THIRD DISTRICT


I, the undersigned, being first sworn, do on oath depose and say:


That I executed the within annual statement as the licensee named in it


or on behalf of the licensee named in it, as the operator, director, or


officer of the licensee named in it, as indicated in it; that I have


read the statement and know its contents; and that the statement is


true.


...............


Subscribed and sworn to before me this ................ day of


.........., 2 .........................................................


Notary Public in and for Alaska


My commission expires: