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					                                         Surcharge Recipient Organization’s
                     Compliance Procedures for Surcharge Eligibility and Payments

Appendix F - Schedule of Funds Raised From Private Sources




                                 Commemorative Coin Program
                       Schedule of Surcharge Funds Received and Expended


          Recipient Organization:_________________________________________________

          Commemorative Coin Program:____________________________________________
          Program Life                              To
                          From ____________________ ____________________

          Recipient Organization's Fiscal Year
                                                      To
                              From _____________________ ____________________

              Beginning                         FY Surcharge Fund Activity                        Ending
             Fiscal Year                      Surcharge Funds      Surcharge Funds              Fiscal Year
          Surcharge Balance                        Received            Expended                  Balance
                                 Itemized listing of surcharge Categorized listing of
                                 fund payments received        expenditures consistent
                                 from the Mint                 with income statement




          Recipient Organization Representative:
                    Signature                                                            Date
                         Title

          Mint Approval:
                   Signature                                                             Date
                         Title




United States Mint                                             Page F- 1