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Schedule 3

FORMS

FORM 1

(Sections 22 and 41)

SUMMONS TO WITNESS BEFORE THE INTEGRITY COMMISSION

A.B., Complainant

C.D., (name of person in public life alleged to be in breach of the Code of Conduct).

TO E. F., of ...................................................................................................... whereof complaint has been made before the Integrity Commission that C.D. ........................ (state concisely the substance of the complaint) and it has been made to appear to the Commission that you are likely to give material evidence on behalf of the Complaint/person in public life in this behalf:

This is to require you to be and appear at ................. .m. on the ........................ day of ............................... 20.......... at ...................................................................... before the Commission in the said place, to testify what you know concerning the matter of the said complaint.

Dated this .......................................... day of ................. 20 .........

...............................................................................

Chairperson of the Integrity Commission

FORM 2

(Section 11(1))

DECLARATION OF INCOME, ASSETS AND LIABILITIES

Declaration of income, assets and of liabilities at .......................................................... (Declaration Date)

Note:

(a) This declaration must be submitted by 31 January each year or within 3 months of one's first appointment or election to office. Please ensure that every section is completed fully and state whether the information required is applicable or not.

(b) Where any property is held by the declarant, or declarant's spouse in trust for any other person, this should be indicated by a note to that effect.

(d) Where a person is appointed or elected during the course of a year he\she should state the income that he\she earned in the previous calendar year.

(e) Child means the son or daughter of a person including a stepchild, illegitimate child, a child held out by a person as a child of that person or a child adopted under the Adoption Act.

(f) Where the space on this Form is inadequate a separate sheet of paper may be used and signed by the Declarant.

Name of Declarant		Postal Address of Declarant
Position:		Telephone/Fax Number: Email address:
Name of Declarant's spouse:		Address of Declarant's spouse:
Marital Status: Married ÿ Single ÿ Divorced ÿ Separated ÿ
Names of Declarant's Children:	Dates of Birth:		Addresses:

PARTICULARS OF ASSETS HELD BY DECLARANT, AND SPOUSE

CASH IN FINANCIAL INSTITUTIONS

1. TO BE SUPPORTED BY A BANK STATEMENT OR LETTER FROM A FINANCIAL INSTITUTION CONFIRMING BALANCES
Names and addresses of banks In whose name held Account number Balance in account

2. CASH IN EXCESS OF FIVE THOUSAND DOLLARS HELD OTHER THAN IN A FINANCIAL INSTITUTION BY DECLARANTAND SPOUSE
Where held In whose name held Amount

3. BONDS, TREASURY BILLS, STOCKS, DEBENTURES, MUTUAL FUNDS, OTHER FINANCIAL INSTRUMENTS INCLUDING ANY SUCH PROPERTY OVER WHICH A RIGHT OF DISPOSITION RESIDES IN THE DECLARANT AND SPOUSE
No. and description Organisation in which held In whose name held Face value Cost of acquisition where known or market value

4. IMMOVABLE PROPERTY (e.g. HOUSE, LAND AND FARM BUILDINGS) HELD BY DECLARANT AND SPOUSE
Description
Block and parcel number Where situated In whose name held Purchase price Year and value of improvement Estimated current market value

5. SHAREHOLDINGS IN COMPANIES AND HOLDINGS IN PARTNERSHIPS AND JOINT VENTURES
Name of enterprise Name of business No. of shares held In whose name held Current valuation Profit for current year

6. VALUES HELD IN SAFETY DEPOSIT BOXES BY DECLARANT AND SPOUSE
Where held Owner's Name Contents $ Value

7. LIFE INSURANCE POLICIES HELD BY DECLARANT AND SPOUSE
Insurance Company Date issued Date of maturity Name of insured Annual premium Face value Surrender value

8. ANY OTHER PROPERTY OWNED BY DECLARANT AND SPOUSE
Description Owner's name By whom being held In what capacity being held Estimated Value

9. OTHER PROPERTY OWNED BY DECLARANTAND SPOUSE, BEING HELD BY A PERSON OTHER THAN OWNER, WHETHER IN TRUST OR OTHERWISE
Description Owner's name By whom being held In what capacity being held Estimated Market Value in what capacity being held

10. PARTICULARS OF INCOME FROM ALL SOURCES, OF DECLARANT AND SPOUSE (INCLUDING PERQUISITES SUCH AS HOUSE, ENTERTAINMENT ALLOWANCES, RENTALS, ETC.)
Type of income Recipient's name Source Gross amount for period under review

11. PARTICULARS OF LIABILITIES (INCLUDING GUARANTEES) OF DECLARANT AND SPOUSE CERTIFICATE FROM CREDITOR OR PARTYTOWHICH GUARANTEE GIVEN SHOULD BE PROVIDED
Name of person / institution Nature of Liability Original Amount Amount payment Balance outstanding

12. PARTICULARS OF ANY PROPERTY ACQUIRED OR DISPOSED OF BY DECLARANT AND SPOUSE DURING PERIOD OF 12 MONTHS (OR OTHER PERIOD WHERE APPROPRIATE), ENDING ON .......................................
Description of property Acquisition or disposal Cost of acquisition Price of disposal

I do solemnly and sincerely declare that the particulars given by me herein are, to the best of my knowledge, true, accurate and complete.

..............................................

Signature of Declarant

FORM 3

(Section 11(3))

CERTIFICATE

NAME OF DECLARANT ________________________________________

The Commission hereby certifies that it has examined the declaration submitted by the Declarant and is satisfied that the disclosure has been made in accordance with this Act.

_____________________________

Chairperson, Integrity Commission

Dated this .............................. day of ............................ 20 .............