Declarant's Details
Employee ID/Serial #: 
Full Name: 
Substantive Role Title: 
Contact Number: 
Employment Status: 

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  I declare the following:-
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  I have read and understand my responsibilities under the Gifts, Benefits & Bequests (GBB) Policy & Procedure, including the obligation to immediately declare all GBB offered/ accepted/declined.  
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  I will complete a conflicts of interest declaration where the GBB may create an actual, perceived or potential conflicts of interest as required by the Conflicts of Interest Policy.  
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  I will comply with the directions of the delegated officer to deal with and/or manage GBB.  
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  I acknowledge that the information provided in this declaration is to assist in the appropriate visibility, oversight and management of GBB offered/accepted/declined.  
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  I understand that personal and health 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: 

Gifts, Benefits & Bequests details
Date Offered:  
Estimated Value:    round to nearest dollar amount (do not enter cents).
Nature of gift, benefit or bequest:  
Offered By:  
Relationship to the person who
offered the gift, benefit or bequest:
Description of gift, benefit or bequest:  
Description of the context in which the gift or benefit
was offered and/or received:
Action Taken:  
Reason for action taken