13.15 - Attachment 2

Local Government (General) Regulation 2005

Schedule 3A            Form of special disclosure of pecuniary interest

(Clause 195A)

Local Government Act 1993

Form of Special Disclosure of Pecuniary Interest

1 The particulars of this form are to be written in block letters or typed.

2 If any space is insufficient in this form for all the particulars required to complete it, an appendix is to be attached for that purpose which is properly identified and signed by you.

Important information

This information is being collected for the purpose of making a special disclosure of pecuniary interests under sections 451 (4) and (5) of the Local Government Act 1993. You must not make a special disclosure that you know or ought reasonably to know is false or misleading in a material particular. Complaints made about contraventions of these requirements may be referred by the Director-General to the Local Government Pecuniary Interest and Disciplinary Tribunal.


This form must be completed by you before the commencement of the council or council committee meeting in respect of which the special disclosure is being made. The completed form must be tabled at the meeting. Everyone is entitled to inspect it. The special disclosure must be recorded in the minutes of the meeting.

Special disclosure of pecuniary interests

by ____________________________________________________________________________________

            [full name of councillor]

in the matter of __________________________________________________________________________

                        [insert name of environmental planning instrument]

which is to be considered at a meeting of the



[name of council or council committee (as the case requires)]

to be held on the  _________________ day of __________________________ 201 



Pecuniary interest

Address of land in which councillor or an  associated person, company or body has a proprietary interest (the identified land)








Relationship of identified land to councillor

[Tick or cross one box.]

Councillor has interest in the land (e.g. is owner or has other interest arising out of a mortgage, lease, trust, option or contract, or otherwise).

Associated person of councillor has interest in the land.

Associated company or body of councillor has interest in the land.

Matter giving rise to pecuniary interest

Nature of land that is subject to a change

in zone/planning control by proposed

LEP (the subject land)

[Tick or cross one box]

The identified land.

Land that adjoins or is adjacent to or is in proximity to the identified land.

Current zone/planning control

[Insert name of current planning instrument and identify relevant zone/planning control applying to the subject land]


Proposed change of zone/planning control

[Insert name of proposed LEP and identify proposed change of zone/planning control applying to the subject land]


Effect of proposed change of zone/planning control on councillor

[Insert one of the following:

“Appreciable financial gain” or

“Appreciable financial loss”]


[If more than one pecuniary interest is to be declared, reprint the above box and fill in for each additional interest.]


Councillor’s signature





[This form is to be retained by the Council’s general manager and included in full in the minutes of the meeting]