Annual return by a donor 2008/2009 - Page 1 of 3

Elections ACT

Annual return by a donor to
political parties, MLAs or
associated entities	
	This return covers the period:	1/7/[insert year]	to	30/6/[insert year]		
Please refer to the Funding and financial disclosure handbook, Third parties when completing this form.	
	
The due date for lodging this return is [insert day and date]	
	
Enquiries and this form should be addressed to:	
	
Postal Address:	Elections ACT, PO Box 272, Civic Square ACT 2608	
Physical Address:	Ground Floor, North Building, London Circuit, Civic Square, Canberra City, ACT 2601	
	
Telephone: 6205 0224	Fax: 6205 0382	Email: elections@act.gov.au	Website: www.elections.act.gov.au	
			
Donor details	
			
Name of person or organisation making the donation:			
			
Postal address of person or organisation making the donation:			
	Postcode:                    		
			
Details of person completing the return	
			
Full name of person completing the return:			
			
Capacity/position of person completing the return:			
			
(A return for an organisation should be signed by an appropriate officer, such as the company secretary or finance manager.  See signing forms in the Funding and financial disclosure handbook, Third parties.)	
			
Postal address of person completing the return:			
	Postcode:                    		
			
Contact telephone:			
			
I certify that the information contained in this return and its attachments is true and complete.	
Agent’s signature:	/          /          		
			
Approved Form AF2009- 136 approved by the Electoral Commissioner, on 4 June 2009, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2008-46.
	Annual return by a donor 2008/2009- Page 2 of 3
	
Gifts to political parties, MLAs or associated entities	
	
This return covers the period:	1/7/[insert year]	to	30/6/[insert year]		
In the table below, list the name and address of each registered political party, MLA and associated entity to whom gifts totalling [insert amount] or more were made during the financial year, showing the date and value of each gift made.	
Please refer to the definition of gifts in the Funding and financial disclosure handbook, Third parties for information on the kinds of gifts required to be disclosed in this return.	
					
	Name of political party, MLA or associated entity	Address of political party, MLA or associated entity	Date gift made	Value of gift		
			/      /	$		
			/      /	$		
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			/      /	$		
			/      /	$		
			/      /	$		
			/      /	$		
	If space is insufficient please attach additional sheets		
Approved Form AF2009- 136 approved by the Electoral Commissioner, on 4 June 2009, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2008-46.

	Annual return by a donor 2008/2009- Page 3 of 3
	
Receipts	

In this section record details where a gift of [insert amount] or more, or gifts totalling [insert amount] or more, was received during the financial year, and all or part of that gift or gifts was used to make a gift of [insert amount] or gifts totalling [insert amount] or more to a party, MLA or associated entity during the financial year.	

	
Persons and organisations from whom [insert amount] or more was received	

In the table below, list the name, address and the total amount received for those persons and organisations from whom [insert amount] or more was received.

	Name	Address	Amount received		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
	If space is insufficient please attach additional sheets		
Approved Form AF2009-  approved by the Electoral Commissioner, on 4 June 2009, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2008-46.