Ineligible Individual Declaration

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 (
  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the previous five years I have not been a promoter of a tax shelter for which involvement the registration of a charity was revoked.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.

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Ineligible Individual Declaration
lock iconUnique Document ID: 8e95c0e02ab432ec261069714ac02de633217b03
Timestamp Audit
March 8, 2021 5:57 pm MDTIneligible Individual Declaration Uploaded by Andrew Dreger - IP