Statutory Declaration Form
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1USE OF PROCEEDS
FOR TRAVEL ONLY
Community Services
STATUTORY DECLARATION
CANADA
)
IN THE MATTER of
YUKON TERRITORY
)
Lottery Licensing Act
USE OF PROCEEDS
To be filled out by a senior officer of the society
TO WIT:
I, __________________________________________ of __________________________________
(Full name of declarant)
(Name of organization)
do solemnly declare:
1. That I am ______________________________________________________________________
(Declarant’s title/Officer position in the Society)
2. That, the proposed use of proceeds for food have been approved by the Registrar.
3. That, the cost of meals do not include expenses incurred at social events, primarily designed to
serve the personal entertainment of the persons attending, or at fundraising events.
4. That, the cost of meals calculated do not exceed the most current rate set by Government of
Yukon for employees who are on travel status.
5. That, the cost of meals were purchased as part of a program conducted and managed
by _______________________________________ Society on __________________________ .
(Name of Organization)
(Dates of Event )
6. That, the per diem charged is $____________________.
7. That, the amount of people that meal costs covered are ______, as outlined on the travel itinerary.
8. That, the total dollar amount for cost of meals is $ ______________.
And, I make this solemn declaration conscientiously believing it to be true and knowing that is of the same force
and effect as if made under oath and by virtue of the Canada Evidence Act and the Evidence Act.
Declared before me at ________________________ )
In the Territory of Yukon
)
This _______ day of _________________, 20 _____ ) __________________________________
(Signature of Declarant)
______________________________________
NOTARY PUBLIC in and for Yukon
Personal information contained on this form is collected under the Lottery Licensing Act and will be used for the purpose of administering the
Act. For further information, contact the Registrar of Lotteries at (867) 667-5111, toll free within Yukon 1-800-661-0408, ext. 5111.
YG(5715Q)F1 10/2010
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