Form 2—Register of interests of a

Department of | o al Government, Racing and Multicultural Affairs

 Adding a particular
  Place a cross in the ‘add’ box in the left hand column when adding a new particular to your register of
  interests.
  Removing a particular
  Place a cross in the ‘remove’ box in the left hand column when removing a particular from your
  register of interests.
  If there is insufficient space on this form for all of the details you are required to give you may attach
 additional papers for that purpose. You must sign and date each additional paper.
 When completing this form, insert the words ‘not applicable’, where appropriate.
 The completed form (with an envelope marked ‘confidential’) is to be sent, within 30 days of
 commencement of duty or any changes of circumstances to the chief executive officer of your local
 government.
  Related persons
 A person related to a councillor need not include information regarding an interest held jointly or in
  common with the councillor which is already included in the councillor’s register of interests.
  Section notes
 The header of each field includes a reference in italics to the relevant section in Schedule 5 of the
  Local Government Regulation 2012.
 The following notes may assist you with completing your register of interests.
Pe                                          ee eS
      If a councillor, complete section A.                 A related person is a spouse, a dependent child
                                                           or someone whose affairs are so closely
      If a related person to a councillor, complete section | connected with the affairs of a councillor, chief
      A and B.                                             executive officer or senior executive employee,
                                                           that a benefit derived by that person, ora
                                                           substantial part of it, could pass to the
                                                           councillor, chief executive officer or senior
                                                           executive employee.
      21                                                   A Corporation includes—
      1.  If relevant person is a shareholder or has a     e   acompany,
          controlling interest in a corporation state the  e   any body corporate (whether incorporated
          name of the corporation.                             in this jurisdiction or elsewhere), and
      2.  Ifthe relevant person holds a controlling        e   anunincorporated body that under the law
                                                        Signature:_  “#-4AZZ~L            pate: 05/08/2020
  Form 2 — Register of interests of a councillor and their related persons
  Version no: October 2018                                                                Page 9 of 14