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Declaration of interests template

This declaration of financial and other personal interests is to be completed annually by:

  • all SES employees;
  • all employees acting as SES for longer than three months;
  • any other agency employees to whom the agency head considers the declarations policy should apply because of their responsibilities or the nature of their work.

This declaration is to be forwarded on completion to the head of your agency.

Name_____________________________________________

Position Title ______________________________________

Branch/Division_____________________________________

Geographic Location_________________________________

I declare that:

  • I am aware of my responsibilities under the APS Code of Conduct to behave honestly and with integrity, to disclose, and take reasonable steps to avoid, any conflict of interest (real or apparent) in connection with APS employment and not make improper use of (a) inside information, or (b) my duties, status, power or authority, in order to gain, or seek to gain, a benefit or advantage for myself or for any other person;
  • I have read and understood:
    • the APS–wide guidelines covering declarations of personal interests set out in APS Values and Code of Conduct in Practice;
    • any other policies and guidelines on declarations of personal interests that my agency may have put in place;

that require me to declare any private interests or relationships which could or could be seen to influence the decisions I am taking or the advice I am giving;

  • The attached list at Annex A of my private interests and relationships has been prepared on the basis of:
    • the particular roles and responsibilities of my agency;
    • my particular APS roles and responsibilities.

I undertake to immediately inform the head of my agency of any changes to:

  • my responsibilities or to the issue or subjects on which I am required to make decisions or give advice; and
  • my personal circumstances

that could affect the contents of this declaration and to provide an amended declaration/s using this pro forma.

I undertake to declare any private interests or relationships of my immediate family that I am aware of, should circumstances arise in which I consider that they could or could be seen to influence the decisions I am taking or the advice I am giving. I understand that this would require the consent of the family member to the collection by my agency of personal information and a declaration that he/she is aware of the purpose for which the personal information has been collected, the legislative requirements authorising the collection and the third parties to whom the personal information may be disclosed, and consents.  

[Signature

Name

Date]

Declaration of consent by immediate family member to the disclosure of their personal financial and other interests

This declaration is to be completed by the immediate family member/s of the employee should circumstances arise in which the employee considers that the personal financial and other interests of the family member/s could or could be seen to influence the decisions they are taking or the advice they are giving.

Name_______________________________________________________

Relationship to Employee_______________________________________

I am aware that my information has been collected for the purpose of identifying personal and other interests that could or could be seen to influence the decisions that the employee covered by the declarations policy is taking or the advice he/she is giving. I am aware of the Privacy Principles set out in the Privacy Act 1988 which authorise the collection and the third parties to whom my personal information may be disclosed. I consent to the collection of my personal information by (the relevant agency).

The attached list at Annex B of my private interests and relationships has been prepared on that basis.

[Signature

Name

Date]

Annex A

Declaration of personal financial and other interests

Please list any private interests or relationships which could or could be seen to influence the decisions you are taking or the advice you are giving.

The types of interests and relationships that may need to be disclosed include real estate investments, shareholdings, trusts or nominee companies, company directorships or partnerships, other significant sources of income, significant liabilities, gifts, private business, employment, voluntary, social or personal relationships that could or could be seen to impact upon your responsibilities.

[Signature

Name

Date]

Annex B

Declaration of personal financial and other interests of immediate family members

Please list any private interests or relationships which could or could be seen to influence the decisions that the employee covered by the declaration policy is taking or the advice he/she is giving.

The types of interests and relationships that may need to be disclosed include real estate investments, shareholdings, trusts or nominee companies, company directorships or partnerships, other significant sources of income, significant liabilities, gifts, private business, employment, voluntary, social or personal relationships that could or could be seen to impact upon the responsibilities of the employee covered by the declaration policy.

[Signature

Name

Date]