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 DEVELOPMENTPursuant 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) VERIFICATIONSTATE OF ALASKA ssTHIRD DISTRICTI, 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: