Attachment 4 - Registration of Personal Interests Form (Example)1
To <insert name of Government Body>
Particulars of my personal pecuniary and other relevant interests and those of my immediate family of which I am aware are set out in the attached form.
I undertake to advise you should a situation arise where an interest of mine or an interest of a member of my immediate family of which I am aware, whether that interest is pecuniary or otherwise, conflicts, or may reasonably be thought to conflict, with my public duty.
name (block letters)
signature
position
date
Return of Personal Interests of Officer and Immediate Family (including spouse and dependent children)
Real Estate
Real Estate in which a beneficial interest is held other than principal place of residence:
Location
Owner
Purpose for which held
Share Holdings (where total value exceeds $5,000)
Include registered shares, options and current applications (other than nominal share holdings by way of qualification for membership of a credit union, building society or other co-operative society):
Owner of shares
Name of Company (including holding companies and subsidiary companies if applicable)
Directorships in Companies
In regard to any directorships, whether remunerated or not:
Name of Director
Name of Company
Activities of Company whether public or private
Partnerships etc.
Person holding interest
Nature of Operations
Nature of Business Interest
Investments
Investments in bonds, debentures, savings or investment accounts with banks or other financial institutions (exceeding a cumulative value of $5,000).
Person holding Investment
Type of Investment
Body in which Investment is held
Other Assets
List each asset valued at over $5,000 including collections. Household or personal effects and motor vehicles for personal use are to be excluded:
Owner of Asset
Nature of Asset
Employment by a public or private company
Exclude salary from principal public sector employment:
Person receiving income
Nature and annualised amount of income
Any Gifts, Substantial Sponsored Travel or Hospitality exceeding $100
Person receiving Gift etc
Nature of Gift etc
Liabilities
Liabilities exceeding $5,000 other than mortgage over principal place of residence
Person concerned
Nature of liability
Creditor
Other Interests - including membership or office holding of an organisation other than an industrial or professional organisation, or a political party
- Sourced from Department of the Premier and Cabinet Code of Conduct, November 2009.