This electronic disclosure form is most easily used with Microsoft

This electronic disclosure form is most easily used with Microsoft operating systems and a personal
computer.
If you are using Explorer:
http://www.ethicscommissioner.ab.ca/disclosure/members-mla/
Click on March 2016 Disclosure Form
Go to Tools; click file; save as
Save it to your desktop as Mar2016 Disclosure “last Name” (ie: Mar2016disclosureJones)
Open it again, and fill it in. Save it to your desktop again.
Open an email and attach the completed form to: [email protected]
If you are using Firefox:
http://www.ethicscommissioner.ab.ca/disclosure/members-mla/
Click on March 2016 Disclosure Form
At the top right hand corner of the page you will see “Open with Different Viewer”. Click on this.
Go to your “downloads” and open up the PDF document.
Complete form and save it to your desktop as Mar2016 Disclosure “last Name” (ie: Mar2016disclosureJones)
Open an email and attach form to: [email protected]
If you are using Chrome:
http://www.ethicscommissioner.ab.ca/disclosure/members-mla/
Click on March 2016 Disclosure Form
Move your curser to the bottom right of the page until you see the tool bar, click on the save icon and save to your
desktop. Close your browser and open the document – it should be a PDF document. Fill in the form and save as
Mar2016 Disclosure “last Name”. (ie: Mar2016disclosureJones)
Open an email and attach form to: [email protected]
If you choose to use iPad: (not recommended)
http://www.ethicscommissioner.ab.ca/disclosure/membersmla/ Click on March 2016 Disclosure Form
Fill in the form. When you are done, click file; share with email and send to [email protected]
A copy of the form will be saved in your documents on your iPad.
If you have any questions, or difficulties in working with this document, please contact our office at 780-422-2273
or simply print the form, fill it out manually and then submit to our office along with your detailed financial
information.
1
CONFIDENTIAL
OFFICE OF THE ETHICS COMMISSIONER - PROVINCE OF ALBERTA
MEMBER
ANNUAL ETHICS DISCLOSURE STATEMENT
IMPORTANT NOTE: This is a point-in-time collection of information. We expect accurate and updated information.
Complete this form based on your financial affairs for as of:
March 31, 2016
Please save this completed form to your desktop and submit via email to the
Office of the Ethics Commissioner [email protected]
Member Name
Constituency
Preferred Email Address for
Future Contact
DECLARATION:
I am familiar with the requirements of the Conflicts of Interest Act (the Act), Chapter C-23, Revised Statutes of Alberta 2000,
and all subsequent amendments and have sought advice and information from the Office of the Ethics Commissioner of
Alberta where needed to inform myself of my obligations and the information required to be disclosed..
This private disclosure statement accurately discloses, to the best of my knowledge, all assets, liabilities, financial interests,
and income of myself, my spouse, my minor children, and private corporations controlled by any of us, or a combination of
us, as required by the aforementioned Acts.
I hereby certify that there are no conflicts of interest between my official responsibilities and public duties and the matters
contained in this private disclosure statement concerning myself and, as far as is known to me, my spouse, minor children,
and private corporations controlled by any of us.
Financial Statements Included
I Agree
Gift Tracking Form
Ethics Commissioner
Member's Signature
Date of Meeting with Member
Date of Submission of Disclosure Forms
IMPORTANT:
There are four sections in this form. Everyone must Complete Section 1.
Complete Sections 2, 3, and/or 4 ONLY if they are relevant to you.
1. Member Section 1 (ALL must complete)
2. Spouse or Adult Interdependent Partner Section 2 (complete ONLY if married or in an
interdependent relationship)
3. Minor Children Section 3 (complete ONLY if you have children who are under 18 years of age as
of January 1 of this disclosure period)
4. Private Corporations Section 4 (complete one “private corporation” disclosure form for each company
in which you or your spouse are a Director, or where any combination of you, your spouse, and your
children jointly hold more than 20% of the shares of a company).
If you have any questions, please feel free to contact us at 780-422-2273 or [email protected]
2
Section 1
Member
PERSONAL INFORMATION
Spouse/Adult Interdependent Partner
Or if N/A, check here
Given Names of Children under 18
Home Address:
Street Address, City and Postal Code
Birthdate
DD/MO/Year
Work Phone
Cell Phone
Home Phone
Employment Information for previous year
Government of Alberta
Position/Title
MLA
Additional remuneration for additional, special or committee allowances
(i.e. Minister, Whip, Leader, or Committee Chair)
Other
3
Salary
$127,296
CORPORATE INFORMATION
Private Corporations
Name of Corporation/Organization
Director/Officer/Percentage
Ownership
Non-Profit Directorships and Offices (Example: non-profits, community leagues, etc.)
Name of Company/Organization
Position Title
OTHER INCOME
If you have received income from any source in the last year other than previously noted, please
provide details below.
Gross Amount
Rental Income
Disability or pension income
Trust fund income
Other income from Private Corporations
Other income (specify source)
Other income (specify source)
Other income (specify source)
4
ASSETS (include all foreign assets/holdings)
Real Property (For urban properties use municipal assessment value; for farmland, use market value).
Type
Location (street address or
plan, block, lot and city/town)
Assessed Value
(see note above)
Outstanding
mortgage
balance
Who is your
mortgage
with (name of
bank or
institution)
Primary Residence
Secondary Residence
Recreational Property
Rental Properties
Rental Properties
Rental Properties
Other Properties
Other Properties
Bank Accounts and other Deposits
Type
Institution
Chequing
Balance
Savings
Foreign Holdings (if applicable)
Other Deposits or Accounts
Other Deposits or Accounts
Other Deposits or Accounts
Other Deposits or Accounts
5
Pension Rights
Plan
Administrator
Years of Service
Insurance Policies
Insurer and type (whole or term)
Cash Surrender Value or Insured Value
Annuities
Person Paying Annuity
Value
Household and Personal Property
(estimated replacement value, or appraised value if applicable)
Estimated Total Value
Art
Jewelry
Antiques and collectables
Musical instruments and equipment
Household contents
Tools
6
Car/Truck/Boat and Recreational Vehicles (include make and
model), bicycles, and motorbikes.
Year/Make/Model
Vehicle 1:
Vehicle 2:
Vehicle 3:
Recreational Vehicle:
Other Vehicles:
Other Vehicles:
7
Black Book Value
http://www.canadianblackbook.com/
Value
INVESTMENTS
IMPORTANT NOTE: Please attach actual, detailed investment statements showing all specific
investments and holdings as of the disclosure date, or as close as possible, and as provided by your
financial advisor and/or broker including, but not limited to the following:
1 RRSP/RSP/LIRA
2 Stocks, Corporate Bonds and Other Interests in Publicly Traded Securities
3 TFSA
4 RESP
5 GICs/Canada Savings Bonds/Term Deposits, and Government (federal, provincial, or municipal)
Backed Securities
Other Investments and Significant Assets – Not captured above
Details
Attach Statements
8
Value
LIABILITIES (include all foreign liabilities/debts)
Unpaid Municipal or Federal Taxes
Type of unpaid tax
Creditor/Agency
(i.e.: income, property)
Amount Owing
(i.e.: Municipality of X or
Revenue Canada)
Other Loans and Lines of Credit
Creditor
Guarantees
Creditor
Arrears pertaining to
what years
Amount Owing
Principal Debtor
Support Obligations
Relationship to Recipient
Amount Guaranteed
Amount of Monthly Obligation
9
Other Significant Liabilities
Description of Liability
To Whom Owed
Amount Owing
Legal Proceedings
OTHER PERSONAL OR FINANCIAL INTERESTS NOT ALREADY DISCLOSED
Description of Interest
Value
NON-COMMERCIAL AIR TRAVEL – Please list all Non-Commercial Air Travel - Include air
travel previously reported and any travel not yet reported.
OTHER PERTINENT DISCLOSURES
Provide details below:
Have you or your spouse received any inheritances of any kind in the last year?
If so, please provide details.
10
Section 2
Spouse or Adult Interdependent Partner (if applicable)
Important Note: Please attach actual, detailed investment statements
(RRSP&Spousal/RSP/LIRA/Securities/TFSA/GICs/Bonds, etc.) showing all specific investments and holdings
as at the disclosure dates and as provided by your financial advisor and/or broker.
Spouse/Partner Full Name
INCOME:
Source of Income (Company and Position)
Annual Amount
ASSETS (include all foreign holdings) – if joint with spouse, please enter “joint with spouse”
Real Property Address:
Value
Mortgage Co.
Mortgage $
Bank Accounts
Type
Amount
11
Vehicles
Year/Make/Model
Value
Pension Rights
Comments: (Value//Income/Years of Service)
Life Insurance
Annuities
Private Business Interests
Household and personal property
(if separate from Member)
Investments
Attach Statements
LIABILITIES: If joint with spouse, please enter “joint with spouse”
Unpaid Municipal Realty Taxes
Loans or Lines of Credit
Guarantees
Unpaid Income Tax
Support Obligations
Other Significant Liabilities
OTHER FINANCIAL INTERESTS NOT ALREADY DISCLOSED–
if joint with spouse, please enter “joint with spouse”
12
Section 3
Minor Children (under the age of 18)
Please attach actual, detailed investment statements
(RRSP/RSP/RESP/LIRA/Securities/TFSA/GICs/Stocks/Bonds, etc.) showing all specific investments and
holds as at the disclosure date and as provided by your financial advisor and/or broker.
If you have minor child/children under 18 years of age as at January 1, of the reporting
period, please provide details below.
Surname if Different
Minor Child/Children Given Names
INCOME:
Source of Income
Annual Amount
ASSETS: - include foreign holdings if applicable
Bank Accounts
Investments (RESP)
Attach statements
Life Insurance
Annuities/Trust Fund
Other Significant Assets
13
LIABILITIES:
Loans
Unpaid Income Tax
Other Significant Liabilities
OTHER SIGNIFICANT ASSETS OR LIABILITIES (not already disclosed)
14
Section 4
Private Corporations
Note: Please complete one ‘Private Corporation’ disclosure form for each company in which you or
your spouse are a Director, or where any combination of you, your spouse and your children jointly
hold more than 20% of the shares of a company.
NAME OF CORPORATION
GROSS ANNUAL CORPORATE INCOME:
Amount:
ASSETS:
Real Property: Address
Value
Mortgage Co.
Cash and Equivalencies
Investments
Attach statements
Annuities
Other Business Interests
Furnishings/Equipment/
Corporate Property
15
Mortgage $
LIABILITIES
Legal Proceedings
Unpaid Income Tax
Loans and Lines of Credit
Unpaid Municipal Taxes
Other Significant Liabilities
LEGAL PROCEEDINGS
Other Financial Interests Not Already Disclosed
16