Required fields are marked with asterisks (*)

Declaration of Pecuniary Interest

Municipal Conflict of Interest Act, R.S.O. 199, CHAPTER M.50

s.5.1 - Written statement of disclosure

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 secretaty of the committee or local board, as the case may be.

Member's first name

Member's last name

Member's email address

Date of meeting

Agenda item number

Agenda item title

Acknowledgement and declaration

I declare a Pecuniary Interest on the above noted matter, for the following reason(s):

Reason(s) for declaring pecuniary interest

Signed by

Date submitted

Any personal information that is collected is done in accordance with Sections 27, 28, 29a and 30 of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and will be used to contact you concerning the Declaration of Pecuniary Interest form submission. Questions about this collection should be directed to:

Township of Wellesley
4639 Lobsinger Line,
St. Clements, ON N0B 2M0
Telephone: 519-699-3946
Email: gkosch@wellesley.ca