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Code of Conduct FormsPolicy 2-003 Page 15 of 17 Code of Conduct Form A – Disclosure Statement Section 12 of the Code of Conduct regarding the acceptance of gifts and benefits, requires Members to disclose the receipt of certain gifts and benefits if the dollar value of a single gift or benefit exceeds $200 or if the total value of gifts and benefits received from one source in a calendar year exceeds $500. This Disclosure Statement is to be used to report on such gifts and benefits and shall be filed with the Clerk within 30 days of receipt of such gift or benefit, or upon reaching the annual limit. Disclosure Statements are a matter of public record. Nature of Gift or Benefit received: ____________________________________________________________________________ ____________________________________________________________________________ __________________________________________________________ Source of Gift or Benefit: ____________________________________________________________________________ ____________________________________________________________________________ __________________________________________________________ Circumstances under which Gift or Benefit received: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ______________________________________________ Intended use of the Gift or Benefit (i.e. will be donated/provided to the Town): ____________________________________________________________________________ ____________________________________________________________________________ __________________________________________________________ Estimates Value of Gift or Benefit: $___________________________ Date Gift or Benefit was received: ____________________________ (MM/DD/YR) ______________________________ _____________________________ Signature of Member Date Policy 2-003 Page 16 of 17 Code of Conduct Form B – Formal Complaint Form/Affidavit I, (please print name)___________________________ of the Town of Tillsonburg, in the Province of Ontario do solemnly swear (affirm and declare) that the following contents of this complaint form as subscribed by me are true and correct: Applicant(s) Name:______________________ Telephone Number: _______________ Applicant(s) Address: ___________________________________________________ Town: __________________________ Province: _________ Postal Code:_________ Email: ________________________________ I have personal knowledge of the facts as set out in this Affidavit form because: (insert reasons e.g. I work for… I attended a meeting at which... etc.) ______________________________________________________________________ I have reasonable and probable grounds to believe that (please print name of Member in question) ____________________________ has contravened section(s) ___________________of the Code of Conduct of the Town of Tillsonburg. The particulars of which are as follows: (Set out the statements of fact in consecutively numbered paragraphs in the space below, with each paragraph being confined as far as possible to a particular statement of fact. If you require more space please attach additional pages as required and mark each additional page as 2 of 2, 2 of 3, etc.) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Policy 2-003 Page 17 of 17 _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ This affidavit is made for the purpose of requesting that this matter be reviewed by the Town of Tillsonburg appointed Integrity Commissioner and for no other purpose. Sworn (or Affirmed) before me at the Town of Tillsonburg, in the County of Oxford, in the Province of Ontario on ________ day of ____________________, ________. ____________________________ ____________________________ A Commissioner for taking affidavits, etc. Signature of Complainant (to be witnessed by Commissioner) NOTE: This is a sworn (affirmed) affidavit of the deponent only. No investigation has been conducted by this authority to confirm or verify the above sworn information. THE CRIMINAL CODE OF CANADA provides that: everyone commits perjury who, with intent to mislead, makes before a person who is authorized by law to permit it to be made before him a false statement under oath or solemn affirmation by affidavit, solemn declaration or deposition or orally, knowing that the statement is false, is guilty of an indictable offence and liable to a term of imprisonment not exceeding fourteen years (sections 131, 132) or by summary conviction (section 134). Signing a false affidavit may expose you to prosecution under section 131 and 132 or 134 of the Criminal Code, R.S.C 1985, c. C-46 and also to civil liability for defamation.