Statutory Declaration Producer,
Department Head, Key Creative Positions
Nova Scotia Film & Television Production Incentive Fund
For Office Use Only
Date/Time Received: File Number: TO WIT:
In the Matter of Confirmation of payments to Producers, Department Heads and Key Creative
Positions Under the Nova Scotia Film & Television Incentive Fund
This declaration must be made by an officer or other authorized representative of the production company.
I,
, of the City/Town of
in
the Province of Nova Scotia, DO SOLEMNLY DECLARE AS FOLLOWS:
That I, being the authorized representative of
The producer of the program entitled
T
LIST TITLE, NAME, RESIDENCY AND DOLLAR AMOUNT PAID*
AF
To the best of my knowledge, after due inquiry, I hereby certify that the individuals and individuals
associated with the personal services companies listed on the worksheet and employed in [NAME OF
PRODUCTION] are residents of Nova Scotia within the meaning of the Guidelines for the Nova Scotia
Film/TV Incentive Fund and to the best of my knowledge, after due inquiry, no individual so listed has
received and will not as a result of any payment from the Fund pursuant to this application receive,
directly or indirectly subsidized payments exceeding $150,000 for this project.
AND I MAKE THIS SOLEMN DECLARATION CONSCIENTIOUSLY BELIEVING IT TO BE TRUE, AND
KNOWING THAT IT IS OF THE SAME FORCE AND EFFECT AS IF MADE UNDER OATH.
DR
DECLARED before me at
in the province of
Day
of
Month
City/Town
,
Print Name of Deponent
this
.
Year
Signature
Commissioner for Oaths in and for the Province of Nova Scotia
Print Name and Date Commission Expires
Title
Print Name
Date (yyy-mm-dd)
Signature
*The amounts paid by the Fund to the persons identified in this form will be disclosed pursuant to the
Accountability in Economic Development Assistance Act (Nova Scotia).
Statutory Declaration Producer, Department Head, Key Creative Positions – NSFPIF | Nova Scotia Business Inc.
Rev 1 June 2015