Fillable CONFIDENTIAL DISCLOSURE REPORT (Deputy Head) APPENDIX B (Government of Nunavut)

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CONFIDENTIAL DISCLOSURE REPORT (Deputy Head) APPENDIX B (Government of Nunavut)

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1
APPENDIX B
CONFIDENTIAL DISCLOSURE REPORT (Deputy Head)
Name
Position Title
Place of Work
Department
Date
Name of Spouse¹
Names of Dependent Children²
initial statement (to be filed within 30 days of becoming a deputy head)
annual statement (to be filed on or before March 31 each year)
amended statement ³(to be filed within 30 days of acquisition or disposal of asset or liability)
I disclose the following non-exempt assets, direct and contingent of myself, my spouse and my dependent
children and my outside employment and other activities, which I fully understand may have to be divested,
curtailed or modified if it is determined that such assets, liabilities or activities give rise to a real, apparent or
potential conflict of interest in respect of my duties and responsibilities.
See Instructions at the end of this form. Attach a schedule if there is not enough space.
PART I: DEPUTY HEAD
1. Offices and Directorships
Do you hold offices or directorships that are not required or permitted by the responsibilities of
being Deputy Head, and that are not in a social club or religious organization? If so, give
particulars.
Name of Organization
Type of Organization
2. Employment
Do you engage in employment, other than Deputy Head, or the practice of a profession or carry
on a business, other than managing routine personal financial interests? If so, give particulars.
2
3. Contracts
a. Are you or your spouse or dependent child party to any contract with the
Government of Nunavut? If so, give particulars.
Name of Contracting Parties:
____________________________________________________________________
Date and Term of Contract:
____________________________________________________________________
Nature of Contract:
____________________________________________________________________
Value:
____________________________________________________________________
Circumstances of Contract:
____________________________________________________________________
b. Give particulars of all contracts between the Government of Nunavut and a
corporation controlled by you, your spouse or dependent child or a combination of
them.
Name of Contracting Parties:
____________________________________________________________________
Date and Term of Contract:
____________________________________________________________________
Nature of Contract:
____________________________________________________________________
Value:
____________________________________________________________________
Circumstances of Contract:
____________________________________________________________________
4. Give particulars of all contracts between the Government of Nunavut and a
corporation which is controlled by:
a. A corporation you or your spouse or dependent child (or a combination) control;
b. You, your spouse or dependent child (or a combination) together with one or more
corporations referred to in 3(b) above; or
3
c. Two or more corporations referred to in 3(b) above.
Name of Contracting Parties:
____________________________________________________________________
Date and Term of Contract:
____________________________________________________________________
Nature of Contract:
____________________________________________________________________
Value:
____________________________________________________________________
Circumstances of Contract:
____________________________________________________________________
5. Controlled Corporation
Corporations controlled by Deputy Head, spouse or dependent children. (List
corporations controlled by you, your spouse, or your dependent children, or a
combination of them. List all corporations which are controlled by such
corporation, either wholly or together with you, your spouse or dependent child, or
a combination them).
Name of Corporation:
____________________________________________________________________
Nature of Business:
____________________________________________________________________
Value of interest in Corporation:
___________________________________________________________________
PART II DEPUTY HEAD
A. STATEMENT OF INCOME
6. Income from the Government of Nunavut (List all income of $1,000 or more you
have received from any ministry, agency, board or commission of the Government
of Nunavut in the past 12 months).
Description of Income
Source
Value of Interest
4
7. Income from all other sources (List all other sources of income of $1,000 or more
that you have received in the past 12 months).
Description of Income
Source
Value of Interest
B. STATEMENT OF ASSETS
8. Real Property Interests (List all interests in land held by you that is not primarily for
the residential or recreational use of yourself, spouse or your dependent child).
Location of Property
Nature of Interest
9. Bonds, Investments, Securities of a Fixed Value not issued or guaranteed by any
government of Canada or by an agency of any such government, having a value of
$10,000 or more.
Name of Issuer
Value of Interest
10. Mutual Funds that are not open-ended having a value of $10,000 or more.
Name of Instrument
Value of Interest
11. Shares and other Interests in public and private corporations having a value of
$10,000 or more.
Name of Corporation Description of Interest Value of
Interest
5
12. Interests in Sole Proprietorships, Partnerships and Joint Ventures.
Name of
Corporation
Description of
Business
Description of Interest Value of
Interest
13. Registered Retirement Savings Plans that are self-administered having a value of
$10,000 or more.
Plan number Name and Address of
Trustee
Assets Value
14. Personal Property having a value of $10,000 or more and not used for
transportation, household, educational, recreational, social or aesthetic purposes.
Description of Property Value of
Interest
15. Other Assets having a value of $10,000 or more (List all other assets owned by you
which have not been included above and which require disclosure).
Description of Property Value of
Interest
6
C. STATEMENT OF LIABILITIES
16. Mortgages having a value of $10,000 or more.
Description and Address
of Mortgaged Property
Name of
Mortgagor
Address of
Mortgagee
Value
17. Unpaid Property Taxes.
Description and Address
of Property
Period for
Unpaid
Taxes
Municipality or body
who which taxes are
owed
Amount of Tax
including arrears
and penalties
18. Loans (List all loans other than mortgages).
Creditor
Address
Amount outstanding
19. Guarantees.
Creditor Address Principal Debtor Address Amount
Outstanding
20. Unpaid Income Tax.
Creditor
Amount owed including arrears and
penalties
7
21. Other current and recently settled liabilities.
Description of
Liability
Name and Address of Person to
whom liability is owed
Amount
PART III: SPOUSE
This Part will be completed by Deputy Head for his or her spouse.
Spouse’s Name: _________________________________________________________
Home Address:
_________________________________________________________
Telephone: _________________________________________________________
A. STATEMENT OF INCOME
1. Income from the Government of Nunavut (List all income of $1,000 or more your
spouse has received from any ministry, agency, board or commission of the
Government of Nunavut in the past 12 months).
Description of Income Source Value of
Interest
2. Income from all other sources (List all other sources of income of $1,000 or more
that your spouse has received in the past 12 months).
Description of Income Source Value of
Interest
8
B. STATEMENT OF ASSETS
3. Real Property Interests (List all interests in land held by you that is not primarily for
the residential or recreation use of yourself, spouse or your dependent child).
Location of Property
Nature of Interest
4. Bonds, Investments, Securities of a Fixed Value not issued or guaranteed by any
government of Canada or by an agency of any such government, having a value of
$10,000 or more.
Name of Issuer
Value of Interest
5. Mutual Funds that are not open-ended having a value of $10,000 or more.
Name of Instrument
Value of Interest
6. Shares and other Interests in public and private corporations having a value of
$10,000 or more.
Name of Corporation
Description of Interest
Value of Interest
7. Interests in Sole Proprietorships, Partnerships and Joint Ventures.
Name of
Corporation
Description of
Business
Description of
Interest
Value of Interest
9
8. Registered Retirement Savings Plans that are self-administered having a value of
$10,000 or more.
Plan number Name and Address
of Trustee
Assets Value
9. Personal Property having a value of $10,000 or more and not used for
transportation, household, educational, recreational, social or aesthetic purposes.
Description of Property
Value of Interest
10. Other Assets having a value of $10,000 or more (List all other assets owned by you
which have not been included above and which require disclosure).
Description of Property
Value of Interest
C. STATEMENT OF LIABILITIES
11. Mortgages having a value of $10,000 or more.
Description and Address of
Mortgaged Property
Name of
Mortgagor
Address of
Mortgagee
Value
12. Unpaid Property Taxes
Description and Address of
Property
Period
for
Unpaid
Taxes
Municipality or body
who which taxes are
owed
Amount of Tax
including arrears
and penalties
10
13. Loans (List all loans other than mortgages).
Creditor
Address
Amount outstanding
14. Guarantees.
Creditor Address Principal Debtor Address Amount
Outstanding
15. Unpaid Income Tax.
Creditor Amount owed including arrears and
penalties
16. Other Liabilities.
Description of
Liability
Name and Address of Person to
whom liability is owed
Amount
D. STATEMENT OF CONTRACTS.
17. List of all contracts between the Government of Nunavut and your spouse.
Name of
Contracting
parties
Date and Term
of Contract
Name of Contract Value Circumstances
of Contract
11
18. Are any of these contracts held by your spouse for you or on your behalf? If so,
give particulars.
PART IV DEPENDENT CHILDREN
The following Part is to be completed by Deputy Head if he or she has dependent children.
Names of dependent
children
Dates of Birth of dependent
children
Home address of dependent
children
A. STATEMENT OF INCOME
1. Income from the Government of Nunavut (List all income of $1,000 or more your
dependent children have received from any ministry, agency, board or commission
of the Government of Nunavut in the past 12 months).
Description of Income
Source
Value of Interest
12
2. Income from all other sources (List all other sources of income of $1,000 or more
that your dependent children have received in the past 12 months).
Description of Income
Source
Value of Interest
B. STATEMENT OF ASSETS
3. Real Property Interests (List all interests in land held by you that is not primarily for
the residential or recreation use of yourself, spouse or your dependent child).
Name of Child
Location of Property
Nature of Interest
Value of Interest
4. Bonds, Investments, Securities of a Fixed Value not issued or guaranteed by any
government of Canada or by an agency of any such government, having a value of
$10,000 or more.
Name of Child
Name of Issuer
Value of Interest
5. Mutual Funds that are not open-ended having a value of $10,000 or more.
Name of Child Name of
Instrument
Address Number of
Units of
Shares
Value of
Interest
13
6. Shares and other Interests in public and private corporations having a value of
$10,000 or more.
Name of Child Name of
Corporation
Description of Interest Value of Interest
7. Interests in Sole Proprietorships and Joint Ventures.
Name of Child Name of
Corporation
Description of
Business
Description of
Interest
Value of
Interest
8. Registered Retirement Savings Plans that are self-administered having a value of
$10,000 or more.
Name of Child Plan
number
Name and Address
of Trustee
Assets Value
9. Personal Property having a value of $10,000 or more and not used for
transportation, household, educational, recreational, social or aesthetic purposes.
Name of Child Description of Property Value of
Interest
14
10. Other Assets having a value of $10,000 or more (List all other assets owned by you
which have not been included above and which require disclosure).
Name of Child Description of Property Value of
Interest
15
C. STATEMENT OF LIABILITIES
11. Mortgages having a value of $10,000 or more.
Name of
Child
Description and
Address of
Mortgaged
Property
Name of
Mortgagor
Address of
Mortgagee
Value
12. Unpaid Property Taxes
Name of Child
and Description
and Address of
Property
Period for Unpaid
Taxes
Municipality or body
who which taxes are
owed
Amount of Tax
including arrears
and penalties
13. Loans (List all loans other than mortgages).
Name of Child
Creditor
Address
Amount outstanding
14. Guarantees.
Name of
Child
Address Principal Debtor Address Amount
Outstanding
16
15. Children’s Unpaid Income Tax.
Name of Child Year Amount owed including
arrears and penalties.
16. Other Liabilities.
Name of Child Description of
Liability
Name and Address of Person to
whom liability is owed
Amount
E. STATEMENT OF CONTRACTS.
17. List of all contracts between the Government of Nunavut and your dependent
children.
Name of
Contracting
parties
Date and
Term of
Contract
Name of Contract Value Circumstances
of Contract
18. Are any of these contracts held by your dependent children for you or on your
behalf? If so, give particulars.
17
Declaration
I declare that information contained in this statement is, to the best of my knowledge,
information and belief, a full and true disclosure of my, my spouse’s and my dependent
child(ren)’s interests as of ____________________, 20____, as required by the Code of Values
and Ethics.
Declared at ______________________
In the Territory of Nunavut, this_______
Day of ____________ 20___, before me
______________________________________
________________________________
(Commissioner for oaths, judge, notary public)
RESET FORM
18
INSTRUCTIONS
¹Spouse means either of two individuals who are married to each other of living together in a conjugal relationship outside of
marriage
²Dependent child means 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.
³For an amended statement, list only changes since last disclosure statement and indicate whether they are acquisitions or
disposals.
Instructions: Do not include:
7. A source of income that paid less than $1,000
Cash and deposits
Support payments
8. 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 in interest in real property of a corporation of which you are a shareholder.
9. 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
21. Debt that is a current and ordinary household and personal living expense of yours or your spouse or your dependent children
Debt in respect of an automobile, a boat used for recreational purposes, or recreational vehicles of yours, 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, your spouse or your dependent
children
Is debt in respect of an interest of yours that is not required to be disclosed
Is less than $5,000
List only transfers or settlements since you were offered the position of deputy head or since your last disclosure statement was
filed. A disclosed asset or liability is an asset or liability required to be disclosed whether or not previously included in a disclosure
statement.
Appendix B of Code of Values and Ethics sets out the assets and liabilities which must be disclosed:
• the source and amount of any income received by the public servant, his or her spouse and his or her dependent children
during the previous 12 months;
• all assets, liabilities and financial interests held by the public servant, his or her spouse and his or her dependent children;
• all assets, liabilities and financial interests that are held by a corporation in which the public servant, singly or collectively with
his or her spouse or dependent children, has a controlling interest.
Appendix B.2 of the Code of Values and Ethics sets out the assets and liabilities which do not need to be disclosed:
• residences and recreational properties used or intended for use by the public servant or his or her family;
• assets, liabilities and financial interests with a value of less than $5,000;
• a source of income that pays less than $1,000 in a 12 month period;
• household goods and personal belongings;
• vehicles, snowmobiles, all-terrain vehicles, boats and other personal property used for transportation or for hunting, fishing or
recreational purposes;
• cash and deposits;
• bonds, investments and securities of fixed value issued or guaranteed by any government or government agency in Canada;
• guaranteed investment certificates or similar financial instruments;
• registered retirement savings plans, registered education savings plans, pension plans or senior management benefit plans
that are not self-administered;
• investments in open-ended mutual funds;
• annuities and life insurance policies;
• pension rights;
• support payments.
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CONFIDENTIAL DISCLOSURE REPORT (Deputy Head) APPENDIX B (Government of Nunavut)

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