Annual return by a donor [insert year] - 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 for annual returns 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, if different from above:			
			
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.)	
			
Postal address of person completing the return, if different from above:			
	Postcode:                    		
			
Contact telephone:			
			
Email:			
			
I certify that the information contained in this return and its attachments is true and complete.	
Signature of person completing return:	/          /          		

Approved Form AF2010 - 116  approved by the Electoral Commissioner, on 10 June 2010, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2009-136.
	Annual return by a donor [insert year]- Page 2 of 3
	
Gifts to political parties, MLAs or associated entities	

1:  Political parties, MLAs and/or associated entities gifted $1000 or more
In the table below, list the name and address of each registered political party, MLA and associated entity to whom gifts totalling $1000 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 for annual returns 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 AF2010-116  approved by the Electoral Commissioner, on 10 June 2010, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2009-136.
	Annual return by a donor [insert year]- Page 3 of 3
	
Receipts	
	
2.  Persons and organisations from whom gifts of $1000 or more was received
In the table below list the name, address and the total amount received for those persons and organisations from whom one or more gifts totalling $1000 or more was received during the financial year, where all or part of the gift or gifts was used to make one or more gifts totalling $1000 or more to a party, MLA or associated entity during the financial year.

	Name	Address	Amount received		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
			$		
	If space is insufficient please attach additional sheets		

Approved Form AF2010-116  approved by the Electoral Commissioner, on 10 June 2010, under s. 340A of the Electoral Act 1992.  
This approval revokes the form AF2009-136.