1 The particulars required to complete this form must be written in block letters or typed.
2 Omit matter marked with an asterisk (*) if it is not applicable.
Disclosures of pecuniary interests and other matters by—
| ......................... | as at | ......................... |
| (full name of Member) | | (return date) |
| | | ......................... |
| | | (Member’s signature) |
| | | ......................... |
| | | (date) |
Part A—Disclosures relating to member of parliament—to be made publicly available
Section 1 Real property
| Address of parcel of real property | Nature of interest |
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Direction—
A Member may disclose the following information about a parcel of tenanted real property in which the Member has an interest as an alternative to disclosing the address of the parcel—
(a) a statement that the parcel is a parcel of tenanted real property,
(b) the location of the parcel by suburb or area.
If the Member discloses the location of the parcel by suburb or area instead of the address, the Member must disclose the address in Part B of this return.
Section 2 Trusts
| Name of trust | Description of activities of trust | Nature of interest in trust | Interests held by trust |
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Direction—
A Member may disclose the following information about a parcel of tenanted real property in which a trust has an interest as an alternative to disclosing the address of the parcel—
(a) a statement that the parcel is a parcel of tenanted real property,
(b) the location of the parcel by suburb or area.
If the Member discloses the location of the parcel by suburb or area instead of the address, the Member must disclose the address in Part B of this return.
Section 3 Interests and positions in corporations
| Name and address of corporation | Nature of interest or description of position held | Description of principal objects of corporation, if corporation is not a listed corporation |
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Section 4 Positions in trade unions and professional or business associations
| Name of union or association and description of position held |
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Section 5 Debts
| Disclosure of information about debts |
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Section 6 Sources of income
6.1 Income from employment, offices, partnerships and services
6.1.1 Income received as employee
| Name of occupation | Description of kinds of services provided | Name and address of employer | Description of business carried on by employer, if services provided relate to Member’s position as a Member |
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6.1.2 Income received as holder of office
| Name or title of office and description of kinds of services provided | Name and address of corporation or body, if any, in which office is held | Description of business carried on by entity, if services provided relate to Member’s position as a Member |
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6.1.3 Income from partnership
| Name of occupation, if any | Description of kinds of services provided | Name and address of partnership | Description of business carried on by partnership, if services provided relate to Member’s position as a Member |
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6.1.4 Income from services provided under another contract, agreement or arrangement
| Name of occupation, if any, and description of services provided | Names and addresses of parties to contract, agreement or arrangement to provide services | Description of business carried on by other parties, if services provided relate to Member’s position as a Member |
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6.2 Income from trust
| Name and address of settlor | Name and address of trustee |
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6.3 Other income
| Disclosure of information about other income |
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Section 7 Gifts
| Description of gift received | Name and address of donor |
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Section 8 Contributions to travel
| Name and address of person who made contribution to travel | Dates of travel | Places of travel (name State, Territory or country) |
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Section 9 Dispositions of interests
| Disclosure of disposition of interests |
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Section 10 Water access licences
| Water access licence number | Nature of interest |
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Section 11 Discretionary disclosures
| Disclosures that are discretionary—general |
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Part B—Disclosures relating to tenanted real property—to be kept confidential
Section 1 Real property
| Address of parcel of real property | Nature of interest |
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Direction—
If a Member has, in Part A of this return, disclosed the location of a parcel of tenanted real property in which the Member has an interest by suburb or area as an alternative to disclosing the address of the parcel, the Member must disclose the address of the parcel in this section.
Section 2 Trusts
| Name of trust | Description of activities of trust | Nature of interest in trust | Interests held by trust |
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Direction—
If a Member has, in Part A of this return, disclosed the location of a parcel of tenanted real property in which a trust has an interest by suburb or area as an alternative to disclosing the address of the parcel, the Member must disclose the address of the parcel in this section.