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Code of Conduct Form BCode 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 C ode 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.) Page 1 of 2 _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 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. Page 2 of 2