Elections ACT

Election return by a publisher 	
following the ACT Legislative Assembly election held on	Insert date of the ACT election		
			
Please refer to the Funding and financial disclosure handbook, Broadcasters and publishers when completing this form.	
	
The due date for lodging this return is [insert date 8 weeks after polling day]
(8 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	
Details of publication/journal covered by this return	
			
Name of publication/journal:			
			
Publisher’s business name:			
			
Business address:			
(Acknowledgment of receipt of return will be sent to this address)	Postcode:                    		
			
Details of person completing the return	
			
Full name of person completing the return:			
			
Capacity/position of person completing the return:			
			
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 AF2004-31 under section 340A of the Electoral Act 1992
	Election return by a publisher - Page 2 of 2
	
Electoral advertisements	
	
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	Name and address of firm or person lodging advertisement

(for example,
name and address of the advertising agency)	Name and address of participant on whose authority advertisement was published

(that is, political party, candidate, non-party group, referendum participant, other person or organisation)	Date(s) advertisement was published	Page/folio and space occupied by advertisement	Amount charged

(show nil if no charge)	Was normal commercial rate charged?		
				Page/folio	Column cm				
						$	yes / no		
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						$	yes / no