SENIOR EXECUTIVE PRIVATE INTEREST DECLARATION (SEPID)

Declarant's Details
Employee ID/Serial #: 
Full Name: 
 
Role Title: 
Substantive Position Number: 
Are you moving to a different role?: 
Are you currently in a TAA role?: 
Contact Number: 
Division: 
Employment Status: 

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  I declare the following:-
  I have read and understand my responsibilities under the Code of Ethics and Conduct for NSW government sector employees, including the obligation to declare all my private interests (financial, business, personal or other interests or relationships) known to me at the time of making this declaration.  
  I attest compliance with the requirements outlined in the Gifts, Benefits & Bequests (GBB) Policy & Procedure.  
  I acknowledge that the information provided in this declaration is to assist in the appropriate visibility, oversight and management of private interests.  
  I will take prompt action to manage any actual, perceived or potential conflicts of interest as required by the Conflicts of Interest Policy & Procedure.  
  I understand that personal information collected, managed and disclosed on this form will comply with the requirements of the NSW Privacy Laws as outlined in the Department’s Privacy Management Plan.  
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Delegated Officer (Director level or above)
Delegated Officer's Name: 
Delegated Officer's Role Title: 
Delegated Officer's Email Address:   
Delegated Officer's Contact Number: 

1. Shareholdings
List any shareholdings that you own ($ value NOT required) in the box below. This includes those shareholdings held under a Self Managed Superannuation Fund (SMSF).
Do you have any shareholdings to declare?

2. Trusts / Nominee Companies
List any beneficial interest(s) in family or business trusts or nominee companies in the box below.
Do you have any trusts or nominee companies to declare?

3. Officeholders in Companies including subsidiaries of companies that you are currently involved with (whether public or private)
List any positions you hold: e.g. director, secretary, administrator, appointed liquidator, whether the positions are remunerated or not in the box below.
Do you have any officeholder positions to declare?

4. Proprietor (Sole Trader, Business Name, Partnerships, etc.)
List any interests in businesses that you hold in the box below.
Do you have any business interests to declare?

5. Relatives
List any relative(s) (that you are aware of) employed by DCJ and/or in any agency whose work activities are regulated or funded by DCJ or Cluster in the box below.
Do you have any relatives to declare?

6. Investment Properties
List (including the full address) any real estate investment properties in NSW that you or any person associated with you own.
Do you have any investment properties to declare?

7. Any other Pecuniary and Non-Pecuniary interests
List any other financial or non financial interests (that you are aware of and that has not been referred to elsewhere in this declaration) that you or any persons associated with you hold in the box below. NO $ VALUE should be disclosed. Please do not use acronyms.
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  Include:
  • Investments
  • Liabilities
  • Income
  • Membership of associations
  • Future employment prospects or plans
  • etc
    		•  Exclude:
  • Personal credit cards
  • Cash held in personal bank accounts
  • Novated car leases
  • Employer superannuation guarantee contributions e.g. First State Super (FSS)
    		•
    Do you have any other interests to declare?

    8. Voluntary (unpaid) Work
    List any current voluntary (unpaid) membership of boards, committees, community groups, sporting groups, charities etc. in the box below.
    Do you have any voluntary work to declare?

    9. Secondary Employment
    Do you propose to undertake any paid secondary employment within DCJ or Cluster?
    e.g. working in another area within DCJ or Cluster such as the ‘Helpline’
    Do you propose to undertake any paid private work outside your official DCJ or Cluster position?
    e.g. employment or engagement outside DCJ or Cluster; private practice/business; appointment or engagement in any remunerated position such as committees/boards? etc.

    10. Conflicts of Interest
    Do you need to make a Conflicts of Interest (COI) declaration?