Form

Required fields are marked with asterisks (*)

DISCLOSURE OF PECUNIARY INTEREST AND THE GENERAL NATURE THEREOF WRITTEN STATEMENT

(Municipal Conflict of Interest Act, R.S.O. 1990, c. M.50, s.5.1, 5.2, 6)

In accordance with s.5.1 of the Municipal Conflict of Interest Act, at a meeting at which a member discloses an interest under section 5, or as soon as possible afterwards, the member shall file a written statement of the interest and its general nature with the clerk of the municipality or the secretary of the committee or local board, as the case may be.

This Written Statement of Interest shall be placed in a registry established by the Municipality of Kincardine along with a copy of the declaration of interest recorded in the minutes of the meeting by the Clerk. The registry shall be available for public inspection during regular office hours of the Clerk.

Member's Name:

Type of Meeting

Date of Meeting

Agenda Item Number:

Agenda Item Title

declare a pecuniary interest on the above noted matter, for the following reason(s):

By checking the box below, I confirm that I will not:

vote on any question in respect of the matter, I will not take part in discussion on any question in respect of the matter, and I will not attempt in any way whether before, during or after the meeting to influence the voting on any such question.

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