MLAs annual return [insert year] - Page 1 of 3

Elections ACT

Member of the Legislative Assembly
annual return for the [insert year] financial year	
	This return covers the period:	/       /	to	/       /		
		1/7/[insert year] or the date the MLA commenced as an MLA		30/6/[insert year] or the date the MLA ceased to be an MLA		
Please refer to the Funding and financial disclosure handbook for annual returns when completing this form.	
	
The due date for lodging this return is [insert day and date]	
	
Enquiries and returns 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	
	
MLA details	
			
Name of MLA:			
			
Postal address:			
	Postcode:                    		
I certify that the information contained in this return and its attachments is true and complete.	
MLA’s signature:	/          /          		
		
Reporting agent’s details (Complete only if reporting agent is not the MLA)	
			
Name of reporting agent:			
			
Postal address:			
	Postcode:                    		
			
Email:			
			
I certify that the information contained in this return and its attachments is true and complete.	
Agent’s signature:	/          /          		
			
Approved Form AF2010 - 113  approved by the Electoral Commissioner, on 10 June 2010, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2008-48.
	MLAs annual return [insert year] - Page 2 of 3

Gifts	
	
1.  Total gifts this financial year	$		
This total includes all gifts received by the MLA in his or her capacity as an MLA.	
Importantly:	
•	the total must include all gifts received by, or on behalf of, an MLA in his or her capacity as an MLA;
•	do not include receipts of a personal nature (for example, income, salary and private gifts for personal use);
•	all transactions, including those of less than $1000, must be included in the total;
•	all figures must be gross; and
•	this total includes monetary receipts and gifts-in-kind (as defined in the Funding and financial disclosure handbook for annual returns).	
	
2.  Persons and organisations from whom $1000 or more was received	
•	In the table below, list the name, address and the total amount given by those persons and organisations from whom $1000 or more was received.
•	In determining whether the $1000 threshold has been reached, amounts of less than $1000 need not be counted.
•	Only amounts received by, or on behalf of, an MLA in his or her capacity as an MLA are to be included; do not show receipts of a personal nature (for example, income, salary and private gifts for personal use).	
	
	Name	Address	Amount received		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
	If space is insufficient please attach additional sheets		

Approved Form AF2010 -113   approved by the Electoral Commissioner, on 10 June 2010, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2008-48.
	MLAs annual return [insert year] - Page 3 of 3
	
Payments	
			
3.  Total payments this financial year	$		
•	This total includes all payments by the MLA, in his or her capacity as an MLA, for all categories of payments as defined under electoral expenditure in the Funding and financial disclosure handbook for annual returns.  This does not include amounts paid by or on behalf of an MLA using funds provided by the Legislative Assembly to assist the MLA in exercising his or her functions as an MLA.
•	All transactions, including those of less than $1000, must be included in the total.
•	All figures must be gross.	
	
Outstanding debts as at 30 June	
			
4.  Total debts as at 30 June	$		
•	This total includes all debts, overdrafts and unpaid accounts of the MLA, in his or her capacity as an MLA, for all categories of debts as defined under electoral expenditure in the Funding and financial disclosure handbook for annual returns.
•	All debts, including those of less than $1000, must be included in the total.
•	All figures must be gross.	
	
5.  Persons and organisations to whom $1000 or more is owed	
In the table below, list the name, address and the total amount outstanding for those persons and organisations to whom $1000 or more is owed for all categories of debts as defined under electoral expenditure in the Funding and financial disclosure handbook for annual returns.  All amounts must be included when determining if the threshold has been reached.	
	Name	Address	Amount Owed		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			
	If space is insufficient please attach additional sheets		

Approved Form AF2010 - 113  approved by the Electoral Commissioner, on 10 June 2010, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2008-48