FORM 72H

STATEMENT OF MONIES RECEIVED

THE KING'S BENCH

Centre

[Title of Proceeding]

MONIES RECEIVED

Amount	Amount

received	received

Amount	Date rec'd.	From whom rec'd.	Explanation	as income	as capital

[List monies received in chronological order of receipt.]

Sub-totals:

TOTAL AMOUNT OF MONIES RECEIVED: