Election return by a candidate - Page 1 of 3

Elections ACT

Election return by a candidate	
Following the ACT Legislative Assembly election held on	Insert date of ACT Legislative Assembly election		
			
Please refer to the Funding and financial disclosure handbook, Candidates and Non-Party Groups when completing this form.	
	
The due date for lodging this return is (insert date 15 weeks after polling day)
(15 weeks after polling day)	
	
Enquiries and returns should be addressed to:

ACT Electoral Commission
PO Box 272
CIVIC SQUARE ACT 2608	
Telephone: 6205 0224	Fax: 6205 0382	Email: elections@act.gov.au	Website: www.elections.act.gov.au	
Candidate details	
			
Full name of candidate:			
			
Was the candidate endorsed by a registered political party?		yes		no		
			
If yes, the name of the party:			
			
Electorate contested: 		Brindabella		Ginninderra		Molonglo	
			
Reporting agent’s details 	
			
Name of reporting agent:			
			
Postal address:			
	Postcode:                    		
			
Daytime contact number:			
			
Email:			
			
I certify that the information contained in this return and its attachments is true and complete.	
Agent’s signature:	/          /          		
			
This form is  Approved Form AF2004-28 under section 340A of the Electoral Act 1992
	Election return by a candidate - Page 2 of 3

Gifts received	
	
Refer to the Funding and financial disclosure handbook, Candidates and Non-Party Groups for information about the disclosure period and for a definition of gifts.	
1.  What is the period covered by this section?	/       /	to	Insert date 30 days after election		
	
2.  Total amount of gifts received:	$		
	
3.  Total number of donors:			
	
4.  Details of individual donors:	
In the table below, list the name, address, date, and value of each donation received for those persons and organisations from whom gifts totalling $1500 or more were received.	
	
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	If space is insufficient please attach additional sheets		

	Election return by a candidate - Page 3 of 3
	
Electoral expenditure	
	
This section of the return covers the period:	Insert date 36 days before election	to	Insert date of election day		
	
Set out the total expenditure incurred by, or on behalf of, the candidate, during the pre-election period, in the categories identified below.	
Note:	
	
•	all figures must be gross;	
	
•	only the listed categories of campaign expenditure need be disclosed (for example, travel or telephone costs are not required to be included);	
	
•	expenditure on campaign goods or services used during the pre-election period must be included irrespective of when payment was actually made (for example, the cost of production incurred before the pre-election period of advertisements shown during the campaign period).	
				
	Categories of electoral expenditure	Amount Paid		
	Broadcasting electoral advertisements (including production costs)	$		
	Publishing electoral advertisements (including production costs)	$		
	Displaying electoral advertisements at a theatre or other place of entertainment (including production costs)	$		
	Production of printed electoral matter requiring authorisation (for example, how-to-vote cards, posters and pamphlets)	$		
	Producing and distributing electoral matter addressed to particular persons or organisations (such as direct mailing, including printing and postage)	$		
	Consultant’s or advertising agent’s fees in respect of services provided or material used relating to the election	$		
	Opinion polling and other electoral research	$