Devonport City Council

Public Interest Disclosure Form v1


Your Informtion:

Full Name:  

Address:

Contact Number:   

Email:

 

Categories of Public Interest Disclosure:

 

Disclosure Details:

Do you work for a public authority?

Does this relate to one or more individuals?

When did the alleged events occur? 

Summary of matters to disclosure:

 

Additional Information:

Description of any documents provided or name/s of witnesses

Have you reported this information to any other person or authority?

 

Agreement:

By signing this form you agree that the information you have been provided is true and accurate to the best of your knowledge and understand that under Section 87(1) of the Public Interest disclosures Act 2002, it is an offence for a person to knowingly provide false information under the Act to certain officers (including the Ombudsman) with the intention that it be acted on as a disclosed matter. The provision provides for a maximum penalty of 240 penalty units or two year’s imprisonment, or both.

Leave this empty:

Signature arrow
Devonport City Council https://www.devonport.tas.gov.au
Signature Certificate
Document name: Public Interest Disclosure Form v1
lock iconUnique Document ID: e99e7d0636b666c4a51cfbc23c815c53021adddf
Timestamp Audit
March 13, 2020 2:46 pm AESTPublic Interest Disclosure Form v1 Uploaded by Devonport Council - council@devonport.tas.gov.au IP 1.152.104.92