as Defined in Subsection 149.1(1) of the Income Tax Act, RSC 1985, c. 1 (5th Supplement)

I, , serving in the capacity of board member with Lone Prairie Camp registered with Canada Revenue Agency as 815987425RR0001, declare that I am not an ineligible individual by affirming all of the following statements:

1. I have reviewed the provided Ineligible Individual Checklist (https://drive.google.com/file/d/0B31NyAryN0JqQjJwMUJHNEM2X0k/)
2. I do not have an unpardoned criminal record either in Canada or internationally, involving financial dishonesty, tax evasion, theft, fraud, or other offences involving breaches of the public trust; and
3. In the previous five years, I have not been found guilty of a relevant offence either in Canada or internationally. A relevant offence is a noncriminal offence either specifically relevant to the operation of a particular charity or is an offence of financial dishonesty contravening any noncriminal laws such as breaches of legislation for charitable fundraising, consumer protection, or securities regulation; and
4. In the previous five years I have not been a director, trustee, officer, like official, or an individual who controlled or managed either directly or indirectly in any manner whatever, a registered charity during which time the charity engaged in conduct which resulted in the registration of the charity being revoked; and
5. In the previous five years I have not been a promoter of a tax shelter for which involvement the registration of a charity was revoked.

I acknowledge that any dishonesty on my part as to the truth of this declaration:

• may result in a one-year suspension of Lone Prairie Camp to issue official receipts as authorized by Canada Revenue Agency; or
• may result in the charitable status of Lone Prairie Camp being revoked by Canada Revenue Agency; and
• will result in the immediate termination of my role with Lone Prairie Camp, whether I am an employee or volunteer.