Required fields are marked with asterisks (*)

Declaration of Pecuniary Interest

Municipal Conflict of Interest Act, R.S.O. 1990, c. M.50

Council/Committee Member Name

Email Address (to receive a copy of this form)

Please specify which Committee/Local Board

Date of Meeting

Agenda Item Number

Agenda Item Title

I declare a direct/indirect/deemed pecuniary interest on the above-noted matter, for the following reason(s)

Signature

Clear

Date

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