Disclosure of gifts

Details of person making disclosure

Candiate

Donor

Surname

Other names

Details of candidate

Surname

Other names

Are you giving the gift on behalf of someone else

Yes

Details of person making the gift

Name

Address

If someone other than the gift giver is giving the gift, please provide details about that person.

Name

Address

Details of the gift
(value of which is $300 or more, or which is one of 2 or more gifts with a total value of $300 or more)

Date gift promised, received, or made

Value of gift

Description of gift

If you are unable to provide the information required by this form, set out the reasons for not providing it in the space below.

Person making disclosure

I declare that all information and details provided are true and correct, and no known, relevant information is omitted.