HTML version of the form: Affidavit - Objection on Grounds of Conscience to Dues Check-off
Voluntary Response - Essential to Make Decision: Provision of the information requested on this document is voluntary. This information is being collected for the purpose of making a decision concerning objection on the grounds of conscience to duescheck-off being deducted and is essential to making a decision directly affecting you. Refusal to respond will result in union dues beingdeducted. This information will be stored in Personal Information Bank number PSE 901 - Employee Personnel record and will be sharedwith the bargaining agent for confirmation. It is protected from disclosure to unauthorized persons/agencies pursuant to the provisions ofthe Privacy Act. Under the Act you have the right to request access to your personal information, held by a federal government institution,and to request corrections should you believe the information contains errors or omissions.
Instructions: Complete the form. Ensure that the form is signed by a representative of the religious organization and your signaturewitnessed by a commissioner for taking oaths or notary public. Attach a copy of the doctrine of the organization to the affidavit. Send theoriginal form and a copy of the doctrine to your departmental Human Resources officer who will forward the documents to the TreasuryBoard Secretariat for approval.
- Department of:
- Province/Territory:
- County:
In the matter of an agreement between the Treasury Board and the [insert bargaining agent] covering employees in the [insert group].
I [insert name and initials, please print] of [insert city/town], county of [insert county], province/territory of [insert province/territory], make oath and say as follows:
- That I am a member of [insert name of religious organization]
- That the doctrine of the said [insert name of religious organization] is such that as a matter of conscience I am unable to make a financial contribution to an employee organization.
- Attached is a copy of the doctrine of the organization.
- That I shall make contributions to [insert name of charitable organization] equal to the dues I would be subject to under the terms of the agreement to which this affidavit refers.
- Signature of employee:
- Signature and office of representative of religious organization:
- Income Tax Act registration number:
Sworn before me at [insert city/town] in the county of [insert county] this [insert day] day of [insert month], [insert year].
Signature of a commissioner for taking oaths, or notary public:
TBS/SCT 340-52E (Rev. 2003/09)