Declaration of Pecuniary Interest FormDECLARATION OF PECUNIARY INTEREST FORM
Name: ________________________________________
Position: _______________________________________
Council Meeting Date: ____________________________
Open
Closed
I, _________________________________ declare a Pecuniary Interest in regards to
Agenda Item No.: _______________ of the Agenda for the above noted meeting for the
following reason(s):
To the best of my knowledge the information supplied above is correct and complete. I
understand that it is my responsibility to declare any conflict of interest/loyalty, business or
personal that relates directly or indirectly, to myself or any relation in any contract, proposed
contract or other matter when present at a meeting of council where such contract or matter
comes under consideration. I understand that I must withdraw from any meeting during the
discussion of such contract or matter and must not vote in respect of it.
Signature: ______________________________________
Date: __________________________________________
In the case of a Closed Meeting of Council, any member who has declared a Pecuniary
Interest shall forthwith leave the meeting or the part of the meeting during which the matter is
under discussion in accordance with the Town’s Procedural By-Law.
OFFICE OF THE CLERK
Date Received: _______________, 20_____ Time Received: _____________