REVENUE TRACKING TEMPLATE Liberia Extractive Industries Transparency Initiative (LEITI) Distribution of Revenues by the Government of Liberia from

Payments made by Extractive Companies to the General Revenue Account and/ or Other Related Accounts during the year from July 1, 2011 to June 30, 2012 Name of Extractive Company: ______________________________ TIN____________________________

Name of Receiving Institution : __________________________________________________________

Source 1 2 3 4 5 6 7 8 9

Utilization of Funds Organization / Community / Group / Institution Location

Project Name

Actual Amount Received

Actual Amount Disbursed

Receiving Institution Management sign-off

I acknowledge for and on behalf of the Institution our responsibility for the truthful and fair presentation of the attached reporting template in accordance with the reporting guidelines. Specifically, I confirm the following: The information provided in respect of amounts received is complete and has been faithfully extracted from the Institution's accounting records All the amounts received are supported by substantiated documentary evidence The amounts received exclude contributions made before 1 July 2011 and contributions made after 30 June 2012 The classification of amounts received on each line is accurate and does not include amounts received to be reported on other lines The amounts received only reflects transactions with the TIN reflected in this report We attach further information which may assist you in reconciling the amounts received to the records of the relevant taxpayers (delete if not applicable)

1 2 3 4 5

Name & Signature: Head of Institution

Date

REVENUE TRACKING TEMPLATE Liberia Extractive Industries Transparency Initiative (LEITI) Distribution of Revenues by the Government of Liberia from Payments made by Extractive Companies to the General Revenue Account and/ or Other Related Accounts during the year from July 1, 2011 to June 30, 2012 Name of the GOL Agency: _____________________________________ Name of Extractive Company: ______________________________ TIN____________________________

Amount of Contribution to the Consolidated/Other A/C: __________________________ Source 1 2 3 4 5 6 7 8 9 # # # #

I acknowledge for and on behalf of the Ministry/Agency our responsibility for the truthful and fair presentation of the attached reporting template in accordance with the reporting guidelines. Specifically, I confirm the following: The information provided in respect of amounts distrbuted is complete and has been faithfully extracted from the Ministry/Agency's accounting records All the amounts distributed are supported by substantiated documentary evidence The amounts distributed exclude contributions made before 1 July 2011 and contributions made after 30 June 2012 The classification of amounts distributed on each line is accurate and does not include amounts received to be reported on other lines The amounts distributed only reflects transactions with the TIN reflected in this report We attach further information which may assist you in reconciling the amounts received to the records of the relevant taxpayers (delete of not applicable)

Receiving Institution /Organization / Community

Contribution Type

Amount

Government of Liberia Agency sign-off

1 2 3 4 5

Name & Signature: Head of GOL Agency

Date

REVENUE TRACKING TEMPLATE Liberia Extractive Industries Transparency Initiative (LEITI) Defined Revenues intake by the Government of Liberia from Extractive Companies to the General Revenue Account and/ or Other Related Accounts during the year from July 1, 2011 to June 30, 2012 Name of the GOL Agency: ______________________________________________ Name of Extractive Company: _____________________ TIN____________________________

Amount of Contribution to the Consolidated/Other A/C: _________________________ Payment Types 1 2 3 4 5 6 7 8 9 10

I acknowledge for and on behalf of the Ministry/Agency our responsibility for the truthful and fair presentation of the attached reporting template in accordance with the reporting guidelines. Specifically, I confirm the following: The information provided in respect of amounts distrbuted is complete and has been faithfully extracted from the Ministry/Agency's accounting records All the amounts distributed are supported by substantiated documentary evidence The amounts distributed exclude contributions made before 1 July 2011 and contributions made after 30 June 2012 The classification of amounts distributed on each line is accurate and does not include amounts received to be reported on other lines The amounts distributed only reflects transactions with the TIN reflected in this report We attach further information which may assist you in reconciling the amounts received to the records of the relevant taxpayers (delete of not applicable)

Amount to be Paid Actual Amount Paid

Balance to be Paid

County Development Fund Social Development Fund Benefit Trust Fund

Government of Liberia Agency sign-off

1 2 3 4 5

Name & Signature: Head of GOL Agency

Date

port