Request for Amendment
Member of the House of Representatives
Disclosure Return
FINANCIAL YEAR 2022-23	
Completing the Return:
•	This request for amendment should be used to amend a 2022-23 Member of the House of Representatives Disclosure Return lodged with the AEC.
•	This request for amendment is to be completed with reference to the Financial Disclosure Guide for Members of the House of Representatives and Senators.
•	This request for amendment will be available for public inspection from 1 February 2024 at www.aec.gov.au.
•	Any supporting documentation included with this request for amendment may be treated as part of a public disclosure and displayed on the AEC website.
•	The information on this request for amendment is collected under s 319A of the Commonwealth Electoral Act 1918.
Member of the House of Representatives details

Name	
     	

	
2022-23 Return details		
Is this the first amendment 
to the return?	Yes			No			How many other Requests for Amendment have been lodged?	     		

Completing person’s details	
Name	     	
Postal address 	     	
	Suburb/town      	State	     	Postcode       	
Telephone number	(   )       	Fax number	(   )       	
Email address		

Request and Certification	
I request the Electoral Commission amend the Member of the House of Representatives Disclosure Return as detailed in this request for amendment. 
I certify that the information contained in this request for amendment and its attachments is true and complete to the best of my knowledge, information and belief. Where I sign as a representative, I have made due and reasonable inquiries of the member of the House of Representatives on whose behalf I have consented to act as a representative.
I understand that submitting a false or misleading return is an offence under Division 137.1 of the Criminal Code Act 1995.	
Signature				
		Date	     	

How to complete this form:
•	If you are amending an existing entry, complete the ‘Original Entry’ item as it appeared on the original return and then write the amendment in full at the ‘Amended Entry’ item.
•	If adding a completely new entry, write N/A in the ‘Original Entry’ item and complete the ‘Amended Entry’ item in full.
•	Amounts should be reported on a GST inclusive basis.
Part 1: Total of donations received 	
No change to previous information	   OR	
Previous total donations	$      		.00	Amended total donations	$      	.00	
Part 2: Total number of donors	
No change to previous information	   OR	
Previous total donors	     	Amended total donors	     	
Part 3: Details of donations received	
No change to previous information	   OR	
Received from	Date of donation**	Value of donation	
Original 
Entry	Name	     	     	$      	.00	
	Postal address	     		
	Suburb/Town	     	State    	Postcode     		
Amended 
Entry	Name	     	     
.00	$      	.00	
	Postal address	     		
	Suburb/Town	     	State    	Postcode     		
Original 
Entry	Name	     	     	$      	.00	
	Postal address	     		
	Suburb/Town	     	State    	Postcode     		
Amended 
Entry	Name	     	     
.00	$      	.00	
	Postal address	     		
	Suburb/Town	     	State    	Postcode     		
If insufficient space, please attach additional sheets.
*Name and address details
•	If the donation was from an unincorporated association (other than a registered industrial organisation), the name of the association along with the name and address of each member of the executive committee are required.
•	If the donation was from a trust or foundation, the name or description of the trust or foundation along with the names and addresses of the trustees are required.

** In this form donation is a gift within the meaning in section 287(1) of the Electoral Act.