3979 APPENDIX B Formal Complaint FormSchedule ‘B’ Formal Complaint Form/Affidavit
I, ________________________________________(full name) of the Town of Tillsonburg, in the Province of Ontario do
solemnly swear (affirm and declare) that the following contents of this affidavit as subscribed by me are true and correct:
Permanent place of residence: _______________________________________________________________________
Mailing address (if different from above): _______________________________________________________________
I have personal knowledge of the facts as set out in this Affidavit because: (insert reasons e.g. I work for… I attended a
meeting at which... etc.)
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I have reasonable and probable grounds to believe that ____________________________ (specify 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 use the attached Schedule
“A” form and check the applicable box below.)
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Schedule A attached
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 the
__________ day of ___________________________, __________.
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A Commissioner, 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.
Schedule B - Additional Information to Formal Complaint Form / Affidavit
Below is additional information to Appendix B – Formal Complaint Form / Affidavit. If more than one page is
required, please photocopy this blank page and mark each additional page as 2 of 2, 2 of 3, etc. at the top right
corner.
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This Schedule A referred to in the Affidavit of ______________________________ (full name) sworn (or
affirmed) before me on this _________ day of _________________________, ____________.
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A Commissioner for taking affidavits, etc.
The personal information collected on this form is collected under the authority of the Municipal Act, as amended and will
be used to and is used solely for the purposes related to the complaint, the investigation and subsequent report therein.
Questions about this collection should be addressed to the Town Clerk, 519-688-3009 ext, 3224.