Elections ACT

Election return by a broadcaster	
following the ACT Legislative Assembly election held on	Insert date of ACT Legislative Assembly 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 station covered by this return	
			
Station call sign:			
			
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 AF2004-32 under section 340A of the Electoral Act 1992
	Election return by a broadcaster - 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 broadcast

(that is, political party, candidate, non-party group, referendum participant, other person or organisation)	Identification number of advertisement

(if time sheets or schedules are attached)	Date(s) advertisement was broadcast	Times between which advertisement was broadcast	Amount charged

(if network, show only your station’s charge)	Was normal commercial rate charged?		
						$	yes / no		
						$	yes / no		
						$	yes / no		
						$	yes / no		
						$	yes / no		
						$	yes / no		
						$	yes / no		
						$	yes / no		
						$	yes / no		
						$	yes / no		
						$	yes / no