Annual return for a
Member of the Legislative Assembly	
			
For the [insert year] financial year	
This return covers the period:	[insert date]	to	[insert date]		
			
MLA details	

Name of MLA:			

Address of MLA:			
		Postcode:		

Reporting agent’s details	
(If a reporting agent has not been appointed, the MLA must complete the return)	
			
Name of reporting agent:			

Daytime contact number:			

Email:			

I certify that the information contained in this return and its attachments is true and complete.	
Signature of reporting agent:		/        /		

Please refer to the Election funding, expenditure and financial disclosure [insert year] handbook when completing this form.  Authority for collecting information in this form is in section 230 of the Electoral Act 1992.  Information in the form will be made public at the beginning of September [insert year], as required by section 234 of the Electoral Act.	
What must be declared?
•	Information to be included in this return relate only to those receipts, payments and outstanding debts received, made or incurred in his or her capacity as an MLA.
•	The MLA must provide details of receipts (both donations and other receipts), payments and debts relevant to the [insert year] financial year.  Where the MLA became or ceased being an MLA during the year, only details relating to the period when the MLA was an MLA need to be shown.  
•	If the MLA received an amount totalling $1000 or more from the same person or organisation during the year, the name and address of the payer must also be shown on the following pages.  
•	Similarly, if the MLA is indebted for $1000 or more to the same person or organisation, the details of the person or organisation owed the debt must be shown.	
	
Enquiries and returns should be addressed to:
ACT Electoral Commission,  PO Box 272, CIVIC SQUARE ACT 2608
Ground Floor, North Building, London Circuit, Civic Square, Canberra City, ACT 2601	
Phone: 6205 0224	Fax: 6205 0382	Email: elections@act.gov.au	Web: www.elections.act.gov.au	
The due date for lodging this return is Wednesday 31 July [insert year]	
Information on this page is made public except for the reporting agent’s email and phone number.

Summary of receipts, payments and debts

	1.  Receipts 		
			
	Gifts			
	Other receipts			
	Total			
	For gifts-in-kind, show the value of the receipt above.		
	If receipts of $1000 or more were received from the same person or organisation, complete the required details at part 5 on page 3.		

	
	2.  Small anonymous gifts 		
			
	Of the receipts shown at 1 above, show the amount of small anonymous gifts received.		
	Total small anonymous gifts			

	
	3.  Payments 		
			
	Total payments			
	If a payment made by a person on behalf of the MLA was a gift-in-kind (such as paid advertising), show the total value of payments.		

	
	4.  Outstanding debts as at 30 June [insert year] 		
			
	Total debts outstanding			
	For outstanding debts totalling $1000 or more owed to the same person or organisation, complete the required details on page 4.		

 Information on this page is made public.
5.  Receipts totalling $1000 or more	
	
	Name of person, organisation, unincorporated association, trust fund or foundation	For a person or organisation — address	For a company — ABN	Type of receipt ()	Total value of receipt		
		For an unincorporated association — names and addresses of members of the executive committee					
		For a trust fund or foundation — names and addresses of the trustees		Gift	Other receipt			

								

								

								

								

			
	Gifts-in-kind	If a gift is a gift-in-kind, provide the following details:		
	Description of the gift 	How the gift was valued	Value of the gift 		

					
	
Information on this page is made public except for how a gift-in-kind is valued.

	6.  Outstanding debts as at 30 June totalling $1000 or more		
			
	Provide the details of persons and organisations to whom an amount totalling $1000 or more is owed.		
			
	Name 	Address 	Amount owed 		

					

					

					

					

					

					

					

					

					

					

					

			
Information on this page is made public.