Section 112A, Local Electoral Act 2001
I, [name], was a candidate for the following elections held on [date]:
[List all elections at which the candidate stood for election on the above date.]
Part A
Return of electoral donations
I make the following return of all electoral donations received by me that exceed $1,500:
[Set out the following details in respect of every electoral donation received (other than an anonymous electoral donation) that, either on its own or when aggregated with all other donations made by or on behalf of the same donor for use in the same campaign, exceeds $1,500 in sum or value:
the name of the donor:
the address of the donor:
the amount of the donation or, in the case of aggregated donations, the total amount of the donations:
the date the donation was received or, in the case of aggregated donations, the date that each donation was received.
Set out the following details in respect of every anonymous electoral donation received that exceeds $1,500:
the date the donation was received:
the amount of the donation:
the specific election campaign to which the donation was designated:
the amount paid to the electoral officer and the date the payment was made.
In the case of any electoral donation funded from contributions, set out the following details in respect of each contribution that, either on its own or when aggregated with other contributions made by the same contributor to the donation, exceeds $1,500 in sum or value:
the name of the contributor:
the address of the contributor:
the total amount of the contributor's contributions made in relation to the donation.]
Part B
Return of electoral expenses
I make the following return of all electoral expenses incurred by me:
[Set out the following details in respect of every electoral expense incurred by or on behalf of the candidate at the election in respect of any electoral activity:
Sums paid for radio broadcasting, television broadcasting, newspaper advertising, posters, pamphlets, etc, must be set out separately and under separate headings.]