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Part II .

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Disclosure Statements Regulations

made under

Section 35 of the

Conflict of Interest Act

S.N.S. 2010, c. 35

O.I.C. 2011-114 (March 29, 2011), N.S. Reg. 154/2011

Citation

1 These regulations may be cited as the Disclosure Statements Regulations .

Definition

2 In these regulations, “Act” means the Conflict of Interest Act .

Disclosure statement forms

(1) A disclosure statement filed on behalf of a member under clause 8(1)(

a) of the Act

must be in Form A.

(2) A disclosure statement filed on behalf of a member’s spouse and dependent children

under clause 8(1)(

b) of the Act must be in Form B.

Form A: Disclosure Statement on Behalf of Member

Province of Nova Scotia

Conflict of Interest Act

1) Statement information

This disclosure statement is filed on behalf of: _______________________________

(type or print name of member in full) , a member of the House of Assembly/Executive Council.

This statement is an (check one) :

[ ]

initial statement

(to be filed within 30 days of becoming a member)

[ ]

annual statement

(to be filed on or before June 30 each year)

[ ]

amended statement

(to be filed within 90 days of acquisition or disposition of asset or

liability)

2) Information about member

a. Electoral district you represent: ______________________________________

b. List of any appointments held by you under [the] Executive Council Act :

c.Your office address:

(street)

(municipality)

(postal code)

d.Your permanent residence civic address:

(street)

(municipality)

(postal code)

e. Your telephone numbers

• constituency office: _____ - ______ - __________

• caucus office: _____ - ______ - __________

• ministerial office: _____ - ______ - __________

• permanent residence: _____ - ______ - __________

f. Name of your spouse:

Note: “spouse” is defined in the Act as “a person who is married to, the domestic

partner of or living in a conjugal relationship with a member and includes a person of the

same sex as a member, but does not include a person who is separated and living apart

from a member”.

g. Names of your dependent children:

Note: “dependent child” is defined in the Act as “a child who is under the age of

majority or, although over the age of majority, unable, by reason of illness, disability or

other cause, to withdraw from the charge of the person’s parents or provide himself or

herself with reasonable needs”.

3) Exclusions

You are not required to disclose any of the following in this disclosure statement

(subsection 11(3) of the Conflict of Interest Act ):

• assets and financial interests having a value of less than $10,000

• a debt you owe to your spouse, a dependent child or a member of your immediate

family

• a debt owed to you by your spouse, a dependent child or a member of your immediate

family

4) Disclosures

For an amended statement, list only changes since last disclosure statement and indicate

whether they are acquisitions or disposals.

Attach a

schedule if there is not enough space on [the] form.

You must disclose all of the following information (subsection 11(2) of the Conflict of

Interest Act ):

a. the name of every individual or organization that in any manner whatsoever

remunerates or contributes to you, including any reimbursement for expenses made to

you:

Instructions: Indicate capacity in which remuneration is received and include address of

each individual or organization named. Do not indicate amount of remuneration or

contributions. Do not list payments included in item j. )

Individual or

organization

Civic address

Capacity in which

received

b. the issuer or name of any bonds, debentures, holdings in investment funds, mutual

funds, investment trusts or similar securities you have:

Instructions: Do not include:

• Canada Savings Bonds or other investments or securities of fixed value issued or

guaranteed by any level of government in Canada or an agency of a government in

Canada,

• registered retirement savings plans that are not self-directed,

• open-ended mutual funds,

• guaranteed investment certificates or any similar financial instruments,

• annuities and life insurance policies

• pension rights

Do not indicate the amount or value.

Name/issuer of bond, debenture etc.

c. the nature and location of any interest you have in or with respect to real property,

whether situate within or outside the Province:

Instructions: Do not include any interest of yours in or with respect to real property that

is used by you, your spouse or your dependent children for residential or recreational

purposes. Do not list an interest in real property of a corporation of which you are a

shareholder.

Location of property

Nature of interest

d. unless excluded in item b. , the name of every corporation, or subsidiary of a

corporation, in which you hold a beneficial interest, a share warrant or purchase option:

Instructions: Do not indicate the amount or value.

Name of corporation

e. the nature of any interest of yours in property of a kind required to be disclosed in item

b. , c. or d. , and over which you, your spouse or your dependent children have a general

power of appointment or an expectancy under a trust:

Nature of interest in disclosed property

f. any trust established for you, and the names of the trustees and the contributors to the

trust:

Name of trust

Contributors to trust

Trustees

Address for trustees

g. the name of every individual or organization to which you are financially indebted,

Instructions: Do not include a debt that

• is a current and ordinary household and personal living expense of yours or your

spouse or your dependent children

• is in respect of an automobile, a boat used for recreational purposes, or recreational

vehicles of yours or your spouse or your dependent children

• is money or other property entrusted to or received by you in trust for a person other

than you or your spouse or your dependent children

• is in respect of an interest of yours that is not required to be disclosed in item b. or c.

• is less than $10,000

Do not indicate the amount or other details about the debt.

Individual or organization

Address

h. the name of every individual or organization that is financially indebted to you in an

amount greater than $10,000:

Instructions: Do not indicate amount or other details respecting debt.

Individual or organization

Address

i. the name of every individual or organization to which you transferred a disclosed asset

or with whom you settled a disclosed liability:

Instructions: List only transfers or settlements since you became a member or since your

last disclosure statement was filed.

Note: A disclosed asset or liability is an asset or liability required to be disclosed whether

or not previously included in a disclosure statement.

Individual or organization

Address

Asset or liability

j. all payments received by you from a recognized party or an electoral district

association:

Instructions: List only payments received since becoming a member or since last

disclosure statement filed.

Payment source

(recognized party or electoral district assn.)

Amount

Date

k. any gifts with a value greater than $250.00 received by you

Instructions: Do not include gifts from your spouse, dependent children or members of

your immediate family or your spouse’s immediate family. List only gifts received since

becoming a member or since last disclosure statement filed.

Gift

Received from

Value

5) Oath or affirmation

I swear that information contained in this statement is, to the best of my knowledge,

information and belief, a full and true disclosure of my interest as of

_________________, 20___, as required by the Conflict of Interest Act.

Sworn to at _______________________

in the County of ____________ this ___

day of _________________ 20___, before me

(Commissioner, judge, barrister,

commissioner of oaths, notary public –

other than a member of the House of

Assembly or the Executive Council)

(signature of member)

For Use of Commissioner Only

Filed on ____________________, 20___

(signature of Commissioner)

Form B: Disclosure Statement on Behalf of Member’s Spouse and Dependent Children

Province of Nova Scotia

Conflict of Interest Act

1) Statement information

This disclosure statement is filed on behalf of the spouse and dependent children of:

_______________________________ (type or print name of member in full) , a member of the

House of Assembly/Executive Council.

This statement is an (check one) :

[ ]

initial statement

(to be filed within 30 days of becoming a member or within 90 days of

acquiring a spouse)

[ ]

annual statement

(to be filed on or before June 30 each year)

[ ]

amended statement

(to be filed within 90 days of acquisition or disposition of asset or liability)

2) Information about member

a. Electoral district you represent: ______________________________________

b. List of any appointments held by you under Executive Council Act :

c.Your office address:

(street)

(municipality)

(postal code)

d.Your permanent residence civic address:

(street)

(municipality)

(postal code)

e.Your telephone numbers

• constituency office: _____ - ______ - __________

• caucus office: _____ - ______ - __________

• ministerial office: _____ - ______ - __________

• permanent residence: _____ - ______ - __________

f.Name of your spouse:

Note: “spouse” is defined in the Act as “a person who is married to, a domestic partner

of or living in a conjugal relationship with a member and includes a person of the same

sex as a member, but does not include a person who is separated and living apart from a

member”.

g. Names of your dependent children:

Note: “dependent child” is defined in the Act as “a child who is under the age of

majority or, although over the age of majority, unable, by reason of illness, disability or

other cause, to withdraw from the charge of the person’s parents or provide himself or

herself with reasonable needs”.

3) Exclusions

You are not required to disclose any of the following in this disclosure statement

(subsection 11(3) of the Conflict of Interest Act ):

• assets and financial interests having a value of less than $10,000

• a debt you owe to your spouse, a dependent child or a member of your immediate

family

• a debt owed to you by your spouse, a dependent child or a member of your immediate

family

4) Disclosures

For each item, indicate the person to whom the listed item relates (name of spouse or

dependent child). For an amended statement, list only changes since last disclosure

statement and indicate whether they are acquisitions or disposals.

Attach a

schedule if there is not enough space on [the] form.

You must disclose all of the following information (subsection 11(2) of the Conflict of

Interest Act ):

a. the name of every individual or organization that in any manner whatsoever

remunerates or contributes to your spouse or dependent children, including any

reimbursement for expenses made to your spouse or dependent children:

Instructions: Indicate capacity in which remuneration is received and include address of

each individual or organization named. Do not indicate amount of remuneration or

contributions. Do not list payments included in item j. )

Individual or

organization

Civic address

Capacity in

which received

Member of

family

b. the issuer or name of any bonds, debentures, holdings in investment funds, mutual

funds, investment trusts or similar securities your spouse or your dependent children

have:

Instructions: Do not include:

• Canada Savings Bonds or other investments or securities of fixed value issued or

guaranteed by any level of government in Canada or an agency of a government in

Canada,

• registered retirement savings plans that are not self-directed,

• open-ended mutual funds,

• guaranteed investment certificates or any similar financial instruments,

• annuities and life insurance policies

• pension rights

Do not indicate the amount or value.

Name/issuer of bond, debenture etc.

Member of

family

c. the nature and location of any interest your spouse or dependent children have in or

with respect to real property, whether situate within or outside the Province:

Instructions: Do not include any interest in or with respect to real property that is used

by you, your spouse or your dependent children for residential or recreational purposes.

Do not list an interest in real property of a corporation of which you are a shareholder.

Location of property

Nature of

interest

Member of

family

d. unless excluded in b. , the name of every corporation, or subsidiary of a corporation, in

which your spouse or dependent children hold a beneficial interest, a share warrant or

purchase option:

Instructions: Do not indicate the amount or value.

Name of corporation

Member of

family

e. the nature of any interest of your spouse or dependent children in property of a kind

required to be disclosed in b. , c. or d. , and over which you, your spouse or your

dependent children have a general power of appointment or an expectancy under a

trust:

Nature of interest in disclosed property

Member of

family

f. any trust established for your spouse or dependent children, and the names of the

trustees and the contributors to the trust:

Instructions: Do not include a trust established by you or your spouse for your

dependent children.

Name of trust

Contributors to

trust

Trustees

Address for

trustees

Member of

family

g. the name of every individual or organization to which your spouse or dependent

children are financially indebted,

Instructions: Do not include a debt that

• is a current and ordinary household and personal living expense of yours or your

spouse or your dependent children

• is in respect of an automobile, a boat used for recreational purposes, or recreational

vehicles of yours or your spouse or your dependent children

• is money or other property entrusted to or received by you in trust for a person other

than you or your spouse or your dependent children

• is in respect of an interest of yours that is not required to be disclosed in b. or c.

• is less than $10,000

Do not indicate the amount or other details about the debt.

Individual or organization

Address

Member of

family

h. the name of every individual or organization that is financially indebted to your spouse

or dependent children in an amount greater than $10,000:

Instructions: Do not indicate amount or other details respecting debt.

Individual or organization

Address

Member of

family

i. the name of every individual or organization to which your spouse or dependent

children transferred a disclosed asset or with whom they settled a disclosed liability:

Instructions: List only transfers or settlements since you became a member or since your

last disclosure statement was filed.

Note: A disclosed asset or liability is an asset or liability required to be disclosed whether

or not previously included in a disclosure statement.

Individual or organization

Address

Asset or

liability

Member of

family

j. all payments received by you from a recognized party or an electoral district

association:

Instructions: List only payments received since becoming a member or since last

disclosure statement filed.

Payment source

(recognized party or electoral district assn.)

Amount

Date

Member of

family

k. any gifts with a value greater than $250.00 received by your spouse or dependent

children

Instructions: Do not include gifts from your spouse, dependent children or members of

your immediate family or your spouse’s immediate family. List only gifts received since

becoming a member or since last disclosure statement filed.

Gift

Received from

Value

Member of

family

5) Oath or affirmation

I swear that information contained in this statement is, to the best of my knowledge,

information and belief, a full and true disclosure of the interests of my spouse and

dependent children as of _________________, 20___, as required by the Conflict of

Interest Act.

Sworn to at _______________________

in the County of ____________ this ___

day of _________________ 20___, before me

(Commissioner, judge, barrister,

commissioner of oaths, notary public –

other than a member of the House of

Assembly or the Executive Council)

(signature of member)

For Use of Commissioner Only

Filed on ____________________, 20___

(signature of Commissioner)