Municipal Affairs-Forms

Out-of-Province/Country
Travel Authorization
MUNICIPAL AFFAIRS
TYPE OF TRAVEL: Ell Out of Province - Complete this form only.
EH° u t of Country - Complete this form and the attached International Travel by Alberta
Government Public Servants
INSTRUCTIONS
1. Submit the relevant form(s) to the Deputy Minister's office for approval at least 2 weeks prior to date of travel.
2. After completing your trip, attach the form(s) to your expense claim.
Following are the related delegated authorities:
Out of Province/Country
Traveller Recommend Approve
Department Staff Assistant Deputy Minister / Equivalent Deputy Minister
MGB Member / Staff MGB Chairman Deputy Minister
PART A - IDENTIFICATION AND PURPOSE

Name Position Title
Organization/Division/Branch
Office Address Telephone Number
Identify other persons accompanying (if any)
Destination Method of Travel Departure Date (yyyy/mm/dd) Return Date (yyyy/mm/dd)
Purpose of Trip
Signature of Employee Date Signature of Division Head Date
PART B - ESTIMATED EXPEND TURES

Subsistence Transportation Registration fees Miscellaneous (Explain) Total
$ $ $ $ $0.00
PART C - AUTHORIZED SIGNATURE

Approved:
Deputy Minister Date
MA1281 (2012/05) 1
Alberta Municipal Affairs Information Request 2015-R-0088
Page No.001
Out-of-Province/Country
Travel Authorization
jid h e M y fk j
M U N IC IP A L AFFAIRS
TYPE OF TRAVEL: X Out of Province - Complete this form only.
I I Out of Country - Complete this form and the attached International Travel by
Alberta Government Public Servants
INSTRUCTIONS
1. Submit the relevant form(s) to the Deputy Minister's office for approval at least 2 weeks prior to date of travel.
2. After completing your trip, attach the form(s) to your expense claim.
Following are the related delegated authorities:
Out of Province/Country
Traveller Recommend Approve
Department Staff Assistant Deputy Minister / Equivalent Deputy Minister
MGB M em ber/Staff MGB Chairman Deputy Minister
PART A - IDENTIFICATION AND PURPOSE

Name Position Title
Organization/Division/Sranch
Office Address Telephone Number
Identify other persons accompanying (itany)

Note
Destination Method of Travel Departure Date (yyyy/mm/dd) Return Date
(yyyy/mm/dd)
Purpose of Trip
Signature of Employee Date Signature of Division Head Date
PART B - ESTIMATED EXPENDITURES

Subsistence Transportation Registration fees Miscellaneous (Explain) Total
$ $ n/a $ n/a
PART C - AUTHORIZED SIGNATURE
Approved:
A/Managing Director Date
Approved:
Deputy M inister Date
MA1281 (2012/05) 1
Page No.002
As an Expenditure Officer I agree to comply with
the following: Government of Alberta ■
Authority E x p e n d itu re O ffic e r D e s ig n a tio n
Municipal Affairs
An expenditure officer for the relevant department,
regulated fund or Provincial agency shall authorize a
disbursement before it is made. An expenditure officer may
authorize a disbursement only if the expenditure officer is
Name of Expenditure Officer Division
satisfied that the disbursement is in an amount that
complies with the terms of a contract approved by an
expenditure officer or, if there is no contract, that it is Print Name Branch
appropriate in the circumstances.
(Financial Administration Act: s.37)
Job Title
Unless warranted by exceptional circumstances,
administrative support staff are not normally designated as
expenditure officers. However, administrative support staff
may be relied upon to provide the necessary support and Position Classification
assistance to expenditure officers in authorizing
disbursements. Signature of Expenditure Officer
(Financial Management Manual 3-10)
Primary Responsibilities
Expenditure Officers are responsible for:

• Authorizing a proposed expenditure for disbursement
• Certifying that the amount of a proposed expenditure or
disbursement is fair and just if the total amount or the
amount per unit is not specified in a contract or where
there is no written contract
• Initiating an expenditure only if it is for the purpose
authorized by the applicable appropriation or for the
purpose for which a revolving fund was established, and
a disbursement only if it is consistent with the purpose for I
which the money is available, and
• Managing program delivery within budgetary allocations, j
(Accounting & Financial Control Manual 3-11) j A U TH O R ITY: Effective on date of approval by Deputy Minister
A P P R O V A L : As of March 1, 2003, a Criminal Record Check is required of new Expenditure Officers,

Municipal Affairs Policy & Procedures
and persons whose authority is amended due to a change in responsibilities.
Please review the Policy & Procedure which includes
current authority limits posted on our Intranet Site. Requested by:
Ensure that you keep current on changes in policies Print Name Signature of Assistant Deputy Minister / Executive Director Date
and procedures that relate to the expenditures you
Recommended by:
authorize.
Forward this form to:

Financial Services Print Name Signature of Senior Financial Officer Date
Mail Station 14A,
Approved by:
Commerce Place
10155-102 Street
EDMONTON AB T5J 4L4
Signature of Deputy Minister Date
Print Name
FIN MA 1247 (2010/09)
Page No.003
^ A ih e rb fun Government
Contract Control
Finance - MA
Stage - 3
Approval Process and Notes
General
A Contract Control Form (CCF) is required for all contracts and amendments. The CCF is used for the signing phase of the
contract.
Legal Services Review
If any term or condition differs from those in the standard contract template, Legal Services is required to review and approve
the change.
• Legal Services (LS) must review contracts or amendments where template clauses have been added or modified and
ALL non-GoA contract documents; Legal review must be completed prior to sending documents to vendors.
• Requests for legal review should be sent via email and include all background documents {e.g. procurement documents,
contract, previous amendments); if unsure of your legal representative please forward requests to Bill.Nuaent@aov.ab.ca.
• Feedback/advice/corrections received from Legal Services form part of your contract file and MUST be kept.
Approvals
Approvals of the contract activity are to be recorded on the appropriate Contract or Amendment Pre-Approval form (Stage 1
of MA Procurement Policy). A copy of the applicable pre-approval form should accompany the Contract Control Form to
evidence this approval.
Contract Information
File Number: Contract Number:
] New C o ntract 0 Am endm ent
Original Contract Amount: Amended Contract Amount: Start Date (yyyy-mm-dd) Original End Date (yyyy-mm-dd) Amended End Date (yyyy-mm-dd)
Solicitation Number: (if applicable) Legal Name of Contractor/Consultant:
MA Contact Information
Name of Contract Manager: Name of Branch: Telephone Number
Summary of Coding
Business Unit Account Code Fund Code Dept ID Program Code Asset ID
01
Is this a new capital asset? 0 Yes 0 No If "Yes", identify Project Name
Is this an enhancement to 0 Yes 0 No If "Yes", identify Project Name

an existing capital asset? ------------------------------------------------------- -
Non-Canadian Contractor 0 Yes 0 No If "Yes", retain 15% Federal witholding tax.

Approvals:
Were any changes made to clauses in a template? 0 Yes 0 No If "Yes", Legal Services review is required
Name of LS Reviewer Date Sent to LS for Review (yyyy-mm-dd) Date Final Reply Received from LS (yyyy-mm-dd)
Notes/Comments
Contract Manager Date (yyyy-mm-dd) Signature
Direct Report to DM (if<$i,ooo.ooo) Date (yyyy-mm-dd! Signature
SFO (if >$1,000,000) Date (yyyy-mm-dd) Signature
Deputy M i n i s t e r ■ $ ooo non) Date /yyyy-mm-dd; SiqAlberta Municipal Affairs Information Request 2015-R-0088
Page N° .004
Contract Pre-Approval Form
yOXheAbikJ (Contracts $75,000 and less)
Competitive Process
MUNICIPAL AFFAIRS
Section 1: Contracting Summary

Brief description of service (Describe the service to be procured)
Total Estimated Contract (Include all costs, labor and expenses, bv fiscal vear includina all extensions. The total
Amount contract amount is used to determine the procurement method as allowed by policy.
Contract Term (Include all estimated extensions) Desired Contract

E.g. 2 years plus 1 year extension. Start Date
Procurement Method Open Competition: 0 Three Quotes (If getting quotes, must
□ Open Competition(RFP)posted on APC complete section 5 and 6 on page 2)
□ Formal Ftesource List (PQR) sent to all
Pre-Qualified Vendors
Proposed Vendor(s) List all vendors (if available) invited to compete if using non-open competition.
Division / Branch Contract Manager
Section 2: Rationale for Contracting

Business need for the service?
Describe the business need for service. The need for service may be identified in a number of ways including:
environmental scans; gaps in services already provided; input from department employees and others involved in the
delivery of department programs or services; recommendations from business and industry; Ministerial and Corporate
Managers’ requests.
Scope of the Work and Deliverables

Describe the scope of the work and list all major deliverables.
Cost-Benefit Analysis
Provide a cost-benefit analysis for contracting. Is contracting the most cost effective delivery alternative? Have you
considered the cost of managing the contract? Are portions of the project best done internally (for logistical, cost or risk
reasons)? Is it best to go with one big contract versus multiple contracts (e.g. multiple phases or assignments)?
Program Area Response (limit to one sentence)

How does the request align to Ministry goals and priorities?
Why can't the work be done by department staff?
Can the work be delayed? What are the risks?
Are there hiqher than normal risks?
What are the risks if not approved?
Are appropriate accountability measures in place?
Is committee approval time sensitive/why?
Other options which were considered?
Does this agreement set up expectation for future
fundinq/work?
Form version: 20150901 Alberta Municipal Affairs Information Request 2015-R-0088

Page No.005
(Contracts $75,000 and less)
Competitive Process
MUNICIPAL AFFAIRS
Section 3: Approvals
Role Name Signature Date
Contract Manager
Expenditure Officer
(Funds available in budget)
Director
Executive Director
Direct Report to Deputy Minister
Section 4: Additional Information or Comments
Section 5: Quotes
Successful
Amount Proponent
Date Vendor Contacted Quoted (Yes/No) Rationale for Selection
Contract Manager
Expenditure Officer
Legal Services must review any non-GoA contract documents and any contracts where
template clauses have been added or changed prior to being sent to vendors.
Legal Services prefers that requests for review are sent via email and not through ARTS. If unsure of whom your legal
representative is, please forward requests to Bill.Nuaent@qov.ab.ca for assignment.
Legal Services will review your submission, and provide feedback/advice/corrections via email. The email received from
Legal Services will form part of your contract file and MUST be kept.
Form version: 20150901 Alberta Municipal Affairs InfofmgJioncRequest 2015-R-0088

‘ " Page No.006
Contract Amendment Form
MUNICIPAL AFFAIRS

Vendor’s Legal Name J Contract Number
Total Original Contract (Include all costs, labor and expenses, bv fiscal vear includina all extensions. The total
Amount contract amount is used to determine the procurement method as allowed by policy)
Amendment Amount (Include all costs, labor and expenses.)
Total Contract (Original Value + Amendment)
Original Contract Term (Include all estimated extensions) Original (as per contract
E.g. 2 years plus 1 year extension. Contract End or most recent
Date amendment)
Amended Contract Term Desired
Contract End
Date
Procurement Method Open Competition: Non-Open Competition: □ Others (specify)
□ Open Competition(RFP)posted □ Sole Source
on APC
□ Formal Resource List (PQR)
sent to all Pre-Qualified Vendors
Section 2: Rationale for Amendment

Business need for the Amendment?
Describe the need to extend the service (either time or cost or both). The need for service may be identified in a number of
ways including: environmental scans; gaps in services already provided; input from department employees and others
involved in the delivery of department programs or services; recommendations from business and industry; Ministerial and
Corporate Managers ’ requests.

Describe the scope of the work and list all major deliverables. Have these changed, if so why?

Why is the contract being amended?
Why can’t the work be done by department staff?

Page No.007
Contract Amendment Form
^ 4 t hev
MUNICIPAL AFFAIRS

Are there higher than normal risks?____________
What are the risks if not approved?____________
Is committee approval time sensitive/why?______
Other options which were considered?__________
funding/work?________________________
Contract Manager
Expenditure Officer
Director
Executive Director
Contract Review Committee
Senior Financial Officer
Deputy Minister
Amendments must be reviewed by Legal Services prior to being sent to vendors.
Legal Services will require copies of the following to complete their review (non-exhaustive list):
- Request for Proposal (if applicable), including any/all updates
- Signed Contract or Statement of Work or Master Contract
- Previous Amendment(s) (if applicable)
- Vendor proposal (from original solicitation and/or generated due to amendment)
- Vendor work plans/project proposals/etc. (from original solicitation and/or generated due to amendment.)
If these are from the requested amendment, they should be UNSIGNED
- Completed pre-approval form
- Proposed amendment [template available from hun.s://cdms.exi.gov.;ib.ca/CCoE/dct'auh.aspx 1
representative is, please forward requests to Bill.Nugent©gov.ab.ca for assignment.
Form version: 20150901 Alberta Municipal Affairs Information [Request 2015-R-0088

" Page No.008
Source List Approval
yiihevbfcj
MUNICIPAL AFFAIRS
Section 1: PQR Summary

PQR Number
PQR Post Date | PQR Close Date
PQR Information Please include a copy of the following:

• PQR
• Consolidated Scoring Summary
PQR Term Provide term of PQR and any extension periods
Proposed Vendor(s) List all vendors added to the Standing Offer List
Division / Branch PQR Administrator
Section 2 : Rationale for Source List

Describe the business need for service. The need for service may be identified in a number o f ways including:
Managers’ requests.
Overview of the Possible Work

Provide an overview of the possible work and why a source list is required.
Provide a cost-benefit analysis for the source list. Is a list the most cost effective delivery alternative? Have you
considered the cost of managing the PQR? Is it possible to have an internal resource on hand (for logistical, cost or risk
reasons)? Is it best to go with an open source list or have a limited number on the list?

Is there valid justification for the list?
How does the request aliqn to Ministry goals and priorities?
Are there higher than normal risks?

Page No.009
Source List Approval
^ 4 iiw tfc j
MUNICIPAL AFFAIRS
PQR Administrator
Director
Executive Director

SFO
Deputy Minister
Form version: 20150323 Alberta Municipal Affairs InformationRequest 2015-R-0088

J Page No.0010
(Sole Source $10,000 - $75,000)
MUNICIPAL AFFAIRS

Total Contract Amount (include all costs, labor and expenses, bv fiscal vear includina all extensions. The total
contract amount is used to determine the procurement method as allowed by policy.

Procurement Method Non-Open Competition: □ Others (specify)
□ Informal Resource List
Q Sole Source
Proposed Vendor and List vendor (if available) invited to compete if using non-open competition.
Address

Managers' requests.

Circumstances of the Procurement

including the applicable trade exception under Treasury Board’s Procurement and Sole-sourcing Directive

Is there valid justification to sole source?
Page No.0011
(Sole Source $10,000 - $75,000)
MUNICIPAL AFFAIRS
funding/work?
TRADE EXCEPTIONS CAN BE FOUND AT HERE rhttDS://maDortal.aov.ab.ca/CRC/Shared%20Documents/Trade%20E>rceotinnR.prtf f
Reason for sole-source:
Contract Manager
Expenditure Officer
(Funds available in budqet)
Director
Executive Director
Deputy Minister
Legal Services must review any non-GoA contract documents and any contracts where
template clauses have been added or changed prior to being sent to vendors.
representative is, please forward requests to Bill.Nuqent@QOv.ab.ca for assignment.

Page No.0012
yS&h&rbAj (Contracts $75,000 and over)

Competitive Process
MUNICIPAL AFFAIRS

Total Contract Amount (Include all costs, labor and expenses, bv fiscal vear includinq all extensions. The total
contract amount is used to determine the procurement method as allowed by policy.

Procurement Method Open Competition: □ Others (specify)
□ Open Competition(RFP)posted
on A PC
□ Formal Resource List (POR)
sent to all Pre-Qualified Vendors
Proposed Vendor(s) List all vendors (if available) invited to compete if using non-open competition.

Managers' requests.


is committee approval time sensitive/why?
funding/work?

Page No.0013
(Contracts $75,000 and over)
Competitive Process
MUNICIPAL AFFAIRS
Contract Manager
Expenditure Officer
Director
Executive Director

Deputy Minister
Form version: 20150319 Alberta Municipal Affairs InformatiOncRequest 2015-R-0088

Page No.0014
y ^ [h & rb c v j (Sole Source under $10,000)
MUNICIPAL AFFAIRS

Total Contract Amount (Include all costs, labor and expenses, bv fiscal vear includina all extensions. The total
contract amount is used to determine the procurement method as allowed by policy. If the
total value will be over $10,000 this form cannot be used.)
Procurement Method Non-Open Competition: □ Others (specify)
□ Informal Resource List
□ Sole Source
Vendor’s legal name and
Address

Managers ’ requests.

considered the cost of managing the contract? Are portions o f the project best done internally (for logistical, cost or risk
reasons)? Is it best to go with one big contract versus multiple contracts (e.g. multiple phases or assignments)? Use
figures where possible.

Are there hiqher than normal risks?
funding/work?

Page No.0015
v4tb e rtfcj (Sole Source under $10,000)
MUNICIPAL AFFAIRS
Justification for sole-source:
The Vendor’s proposal has been evaluated Cl Yes Q No
Contract Manager
Expenditure Officer
Director
Executive Director
Form version: 20150323 Alberta Municipal Affairs Infopmla|jOrlcPecluest 2015-R-0088

" Page No.0016
PURCHASE PRE-APPROVAL FORM
(Goods under $10,000)
MUNICIPAL AFFAIRS
This form is to be used for the purchase of goods when the total value of like goods is $500.00 or greater
Total Estimated Value of Goods being

Requesting Branch: Contact Person:
purchased:
Description of Goods
Unless circumstances warrant and which are clearly described, contracts that exceed $10,000 for goods should be
awarded through a public competitive bid process.
For requirements under $10,000 in estimated value, purchasers should invite written quotes from at least three
vendors.
Successful
Amount Proponent
Date Vendor Contacted Quoted (Yes/No) Rationale for Selection
i ~^\ O n Standing Offer Standing Offer Number:
Additional comments if required:
Expenditure Officer approval to proceed:
Name: Signature: Date:
Summary of Coding
Business Unit Account Code Fund Code Dept ID Program Code Asset ID
Form version: 20150923 Page 1 of 1

Page No.0017
PURCHASE PRE-APPROVAL FORM
(Goods purchased $10,000 and over)
MUNICIPAL AFFAIRS
Requesting Branch: Contract Manager: Total estimated value of goods
being purchased:
Description of Goods:
Unless circumstances warrant and which are clearly described, purchases $10,000 and over for goods should be
awarded through a competitive bid process.
Please refer to Mandatory Compliance Checklist on Service Alberta’s Contract Centre of Excellence (CCoE) website.
o All purchases made directly by departments are subject to the Alberta/B.C. Trade Investment and Labour
Mobility Agreement (TILMA).
o TILMA's procurement provisions require that open access be provided for all Supplies valued at $10,000 or
greater
o A competitive process must be conducted for all requirements for Supplies, Services and/or Construction at
or over these thresholds.
For above threshold procurements, open tendering is not required in cases where an exception can be justified.
Is the procurement covered by an exception?
] Yes (documentation to be included)

□ No - Proceed to competitive bid process.
For information access Service Alberta's Procurement SharePoint Site
If yes, which exception applies? Explanation of exception:
Absence of bids
J Confidentiality
Emergency
□ Health and social services
Expenditure Officer approval to proceed to contracting (Executive Directors up to $25,000):
Name:______________________________Signature:_______________________________ Date:
Expenditure Officer approval to proceed to contracting (Reporting to DM up to $74,999):

Expenditure Officer approval to proceed to contracting (SFO $75,000 and over)

Expenditure Officer approval to proceed to contracting (Deputy Minister $75,000 and over):
Name:______________________________Signature:_______________________________ Date:
Com pleted form to be included with C ontract Package

Page No.0018
Government of Alberta ■
Municipal Affairs
CONTRACT EVALUATION FORM “
This form is used to assess and document the completion of a contract and evaluate the
services/deliverables provided by the Contractors.
Contractor Name: CONTRACT FILE NO,

Program Code & Dept ID:
Final Contract Amount: $ Actual Cost: $
Commencement Date (m m /d d/yyyy): Termination Date (m m /dd/yyyy):
Contract Manager: Phone Number:
Evaluation on Serviccs/Deliverables contracted:

All services/deliverables received? Yes n No □
Acceptable quality? Yes n No □
Completed within original contract schedule? Yes n No n
If the contract was amended, was it at the department's request? Yes n No □
Within contracted / amended budget?
Would you hire this contractor again?
Yes n No □
Yes □ No □
Other (specify)
If you answered no to any of the above, please provide explanation
Overall Satisfaction with Contractor

!_] Excellent |_| Good LJ Average I~1 Poor
Comments:
I acknowledge that I have reviewed the entire contract file and confirm all documentation is complete and
complies with the Ministry’s Contract Policy.
Signature of Contract Manager: Date:
Corporate Services Review
Completed by:_____________________________________ Date:
Return original signed copy to Financial Services

Page No.0019
Municipal Affairs
Request for a New Dept ID
Date of Request (m m /Hd/jyyyl
Contact Information
Division Division Contact
E-Mail Address Telephone N um ber (include area coda]
Dept ID Information
BU Dept ID Description Short Description Effective Date imm/dd/ww)
4/1/
Program Code Expenditure Officer Nam e (EO)* M anpower Im plications: Yes or No
‘ Reminder: EO Designation Form needs to be completed
Reason/Definition
Tree Update Information

Dept ID Tree is available on th e MA Intranet Site.
Navigation: MA Intranet *> B usiness Units -> Corporate Strategic Services -> Financial Services -> Financial Forms & Resources -> IMAGIC Chartfields
Specify a parent node for Dep t ID Tree {DEPTID_6D_144)
FOR FIN/XNCIAL PLANh ING & ANALYSIS USE ONLY

Approved Financial Planning and Analysis Manager Name Date (m m/dd/yyyyl
Processed Budget Analyst Name Date (m m /dd/yw y) |Dept ID
Processing
Codes List
Updated Budget Analyst Name Date im m /d d / m r)
Pay Combo Code
Yes or No 2 Created Budget Analyst Name Date (mm/dd/yyvy)
DEPTID_BDJL44
Tree Updated Budget Analyst Name Date (mm/dd/yYYY)
Updated Dept ID
Tree Posted on
MA Intranet System Administrator Name Date {rrim/dd/yyYV]
Form and Tree

Yes or N/A Forwarded to HR Budget Analyst Name Date (m m /dd/ywy)
FO R H U M A N R E S O U R C E S S E R V IC E S (a p p lica b le o n ly if D e p t ID h a s m a n p o w e r!
HR Tree Update Name Date (mm/dd/yyyY)
Department
Budget Table
Updated Name Date {mm/dd/yyyY)
If you have any questions, please contact Trevor Eliott at 780-422-8042, otherwise email completed form to Yvonne.Jachawicz@gov.ab.ca

Page No;:002Cr
Municipal Affairs
Request to Inactivate a Dept ID
Date of Request (mm/dd/yyyy)
Contact Information
E-Mail Address Telephone Num ber {include area code)
Dept ID Information
BU Dept ID Dept ID Description Short Description Inactive Date (mm/dd/yyyy)
144
Program Code Expenditure Officer Nam e (EO)* M anpow er Im plications: Yes or No
•Complete EO Designation Form
Reason/Definition

Information on MA Set ID tre es is available on the MA Intranet Site.
Navigation: MA Intranet -> 8 usiness Units -> Corporate Strategic Services -> Financial Services -> Financial Forms & Resources -> IMAGIC Chartfields
Specify a parent node for Dep t ID Tree (DEPTID_BD_144)
FOR FINANCIAL PLANNING & ANALYSIS USE ONLY

Approved Financial Planning and Analysis Manager Name Date [mm/dd/yyyvl
Processed Budget Analyst Name Date {mm/dd/yyyvl
Processing
Codes List
Updated Budget Analyst Name Date {mm/dd/yYw)
DEPTID_BD_144
Tree Updated Budget Analyst Name Date (mm/dd/vWY)
Updated Dept ID
Tree Posted on
MA Intranet System Administrator Name Date (mm/dd/ywy)
Pay Combo Code
Yes or No 2 Created Budget Analyst Name Date (mm/dd/yyw)
Form and Tree

Yes or N/A Forwarded to HR Budget Analyst Name Date (mm/dd/ww)
F O R H U M A N R E S O U R C E S S E R V IC E S [a p p lica b le o n fv if D e p t ID h as m a n p o w e r!
HR Tree Update Name Date {mm/dd/vYW)
Department
Budget Table
Updated Name Date Imm/dd/ww)
If you have any questions, please contact Trevor Eliott at 780-422-8042, otherwise email completed form to Yvonne,Jachowicr(5>R0v ab ca

Page N<0:0021j
Municipal Affairs
Request to Update a Dept ID
Date o f Request (m m /dd /w w )
Contact Information
E-Mail Address Telephone Num ber (include area code)
Dept ID i nformation
BU Dept ID Dept ID Description Short Description Effective Date (mm/dd/yyyy)
Program Code Expenditure Officer Name (EO)* M anpow er Im plications: Yes or No
•Complete EO Designation Form
Reason/Definition

Information on MA Set ID trees is available on the MA Intranet Site.
Navigation: MA Intranet-> Business Units -> Corporate Strategic Services -> Financial Services -> Financial Forms & Resources -> IMAGIC Chartfields
Specify a parent node for Dept ID Tree (DEPTID_BD_144)
FOR FIN/UNCIAL PLANh JNG & ANALYSIS USE ONLY

Approved Financial Planning and Analysis Manager Name Date (mm/dd/yyyy)
Processed Budget Analyst Name D a t e (m m /dd/yyw)
Processing
Cades List
Updated Budget Analyst Name Date (mm/dd/yyyy)
0EPTID_BD_144
Tree Updated Budget Analyst Name Date (mm/dd/vyyy)
Updated Dept ID
Tree Posted on
MA Intranet System Administrator Name Date (mm/dd/yyyy)
Pay Combo Cade
Yes or No 2 Created Budget Analyst Name Date Imm/dd/yyyy)
Form and Tree

Yes or N/A Forwarded to HR Budget Analyst Name Date (mm/dd/yyvy)
FO R H U M A N R E S O U R C E S S E R V IC E S faDolicable o n lv if D e n t ID has m anoow prl

HR Tree Update Name Date (m m /dd /w w )
Department
Budget Table
Updated Name Date (mm/dd/yyyy)
If you have any questions, please contact Trevor Eliott at 780-422-8042, otherwise email completed form to Yvonne.Jachowicz@gov.ab.ca.

Page No/00221
Budget Transfer
Approval Request Municipal Affairs
Fiscal Year 2015-16
Funding FROM:
D ivision:
Description/Rationale for the Transfer:
Program/Dept ID Codes A ccount Code Fund Code Budget Transfer ($)
Total Transfer -
FTE's
ADM/Executive Director Date
Senior Financial Officer Date
Funding TO:
D ivision:
Description/Rationale for the Transfer:
Program/Dept ID Codes Account Code Fund Code Budget Transfer (S)
Total Transfer -
FTE's
ADM/Executive Director Date
Senior Financial Officer Date

Page No.0023
Organization IMAGIS Budget Journal Municipal Affairs
Bus. Unit: 144 - Department Municipal Affairs IMAGIS Ledger Group: ORGEXP
Journal ID: MA Assigned by Financial Planning Budget Entry Type:
Journal Date Budget Period/Fiscal

(mm/dd/yyyy): Year: 2015 (2014-15)
Description/Rationala/Purpose
Does this journal have FTE implications? Yes / No If Yes, how many?
(Decreases) • Increases -
Line Budget Account Program Beginning negative positive Ending
# (7xxxxx) Fund DeptID Code Budget amount amount Budget
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
9 0
10 0
11 0
12 0
13 0
14 0
15 0
TOTALS 0 0 0 0
Completed By (print name) Preparer's Signature
Approved By (print name) Division / Branch / Org. Unit Head Signature (Decreases)
Approved By (print name) Division / Branch / Org. Unit Head Signature (Decreases)

Page No.0024
1/4/2 016 Survey
Close preview
Library Board Basics Workshop Registration - Spruce Grove
I he Public Library Services Branch invites you toattend the

LIBRARY BOARD BASICS W ORKSHOP
to be held
Saturday, February 20, 2016
from 9:30 a.m. to 3:30 p.m.
at
Spruce Grove Public Library
3 5 - 5 Avenue
Spruce Grove, AB
Registration Deadline: Friday, February 12, 2016 at 4:30 p.m.
This workshop is open to all library trustees, library managers andlibrary system staff. It is
designed to help participants supporteffective public library service in their communities and
regions. Inparticular, participants will understand:
• Libraries Act and Regulations and other pertinent legislation.

■ The Alberta public library network.
« Library board roles, responsibilities and relationships.
<■ Other important issues such as finances and effectiveness.
1. Name;
2. Library Board:
3. Phone:
4, email:
5. Food Allergies
https://extranet.gov.ab.ca/opinio6//s?s=28608&tr=6474270 Page No.0025
1/4/2016 Survey
Save | Finish
A registration confirmation email will be sent to all participants on February 16,2016.
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https://extranet.gov.ab.ca/opinio6//s?s=28608&tr=6474270 Alberta Municipal Affairs Information Request 2015-R-00

Page No.00
Municipal Affairs
This statement is to be submitted by municipal and intermunicipal library boards serving fewer
than 10,000 people. Boards serving more than 10,000 people may submit this form or their own
audit.
Return this completed form, or your audit (if applicable), signed by your reviewer, who is
acceptable to council, along with your budget and your grant application form by mail, fax or
email to:
Alberta Municipal Affairs
Public Library Services Branch
803 Standard Life Centre
10405 Jasper Avenue
Edmonton, Alberta T5J 4R7
Phone: (780) 427-4871
Fax: (780)415-8594
mari.scott@gov.ab.ca
Financial reporting requirements are set out in Section 9 of the Libraries Act:
http://w w w.m unicipalaffairs.alberta.ca/publicJibraryJegislation.cfm
2015 Statement of Receipts and Disbursements
Originals, emailed or faxed copies will now be accepted.

Page No.0027
For Library Board
M unicipal Affairs
FINANCIAL REVIEW
For the:
(Legal name of library board*)

“name must match legal library board name on application form
Completed by Financial Reviewer:
Print Name: _______________________________________________________________________
Signature: _________________________________________________________________________
Date: _____________________________________________________________________________
Signature of person/firm approved as financial reviewer as per Section 9 of the Libraries Act
-2 -
Page No.0028
-3 -
Page No.0029
CASH DISBURSEMENTS FOR YEAR Reporting period 2015
Staff , 1 J t ----------, ----------------------------------------------------------------------14,1 ---------L tm attotutu --------
M unicipal Affairs
27 Honoraria (volunteers)
28 Moving expenses
29 Course or conference fees
30 Travel and hospitality (staff)
31 TOTAL STAFF EXPENSES (add lines 26 to 30)
Library resources
32 Books (include freight and purchased cataloguing; do not include money you transfer to
your library system for book purchases, that info goes on Line 56)
33 Periodicals and newspapers
34 Audio-visual materials
35 Digital and electronic resources
36 TOTAL LIBRARY RESOURCES (add lines 32 to 35)
Administration
37 Audit and/or financial review
38 Board expenses (inch honoraria, travel, course and conference fees)
39 Equipment rentals and maintenance
40 Legal fees, bank charges, refunds and deposits (inch GST)
41 Library supplies (inch binding & repair)
42 Association memberships (do not include transfer payments to your library system)
43 Postage and box rental
44 Program expense (inch publieity/advertising, equipment rental, volunteer appreciation,
artist’s fees)
45 Stationery, printing and copier supplies
46 Telephone and telecommunications, inch internet connections
47 Other materials and supplies
48 Other expenses
49 TOTAL ADMINISTRATION EXPENSE (add lines 37 to 48)
-4 -
Page No.0030
CASH DISBURSEMENTS FOR YEAR (cont’d) Reporting period 2015
_ _ _ _ _ --------------------------------------------------------------------------------------- r r r r -------------------------------------------- lviiH ai v i>uaiu
Building co^ts |
M unicipal Affairs
5f Janitorial and maintenance (janitorial service/supplies, maintenance and minor repairs to
building and grounds)
52 Utilities
53 Occupancy costs (to municipality)
54 Rent (to private landlord)
55 TOTAL BUILDING EXPENSE (add lines 50 to 54)
'Transfer payments
56 Transfer to other library boards (please specify boards: may include municipal or library
system boards)
56a
56b
56c
57 Contract payment for library service (e.g., payment to library societies)
57a
57b
58 TOTAL TRANSFER PAYMENTS (add lines 56 and 57)
59 TOTAL OPERATING EXPENDITURE (add lines 31, 36.49, 55, and 58)
60 Loan interest and payments
61 Transfer to other accounts (i.e., capital, operating reserves)
|Capital expenditures
62 Building repairs and renovations (e.g., roof, carpet, partitions)
63 Furniture and equipment
64 Other (please specify)
64a
64b
65 TOTAL CAPITAL EXPENDITURE (add lines 62 to 64)
66 TOTAL CASH DISBURSEMENTS (add lines 59, 60, 6 1, 65)
Cash balance at end of reporting year

67 Cash on hand
68 Total in current bank accounts
69 Total in savings accounts
70 Term deposits
7 i Other committed funds (e.g. trusts and bequests, reserves, capital)
72 TOTAL CLOSING CASH ON HAND (add lines 67 to 7 1)
73 TOTAL CASH ACCOUNTED FOR (add lines 66 and 72)
-5 -
Page No.0031
For .Library Board
Summary of cash receipts and disbursements~statement
M unicipal Affairs
For the year ended, December 31, 2015
Reporting Period 2015

Total cash receipts for the year (from line 24)
SUBTRACT Total cash disbursements for the year (from line 66)
Net cash increase or (decrease) from operations
ADD Total opening cash on hand and in bank (from line 6)
TOTAL CLOSING CASH ON HAND IN BANK (from line 72)
Please continue on to Page 7 if your municipality made any payments on behalf of the Library Board.
Please have the municipal administrator fill out this form.
- 6 -
Page No.0032
DIRECT PAYMENTS
If the municipality pays costs in addition to its local appropriation (line 07) to the library board, this page should
be completed by a municipal administrator. Include only that portion of the municipal expenditure that is paid on
behalf of the library. These figures may be subject to audit. The figures in lines a. to m. should not be included
in the library board's Statem ent o f R eceipts an d D isbursm ents and/or financial statements.
OPERATING EXPENDITURES PAID BY MUNICIPALITY (DIRECT PAYMENTS) Reporting Period 2015

a. S taff (salaries and benefits, m oving expenses, course fees)
b. B uilding maintenance(janitor, supplies, maintenance, and repairs)
c. Insurance
d. U tilities
e. Audit
f. Rent (to private landlord)
g- Telephone
h. Other Expenses
I. TOTAL OPERATING EXPENDITURES PAID BY MUNICIPALITY (add lines a to h) $ -
| O th er ex p en d itu res p a id b y M u n icip a lity |
j- Debenture interest and principal
k. Capital or special grants (i.e., one-tim e grants)
1. Library System appropriation (Contribution o f your M unicipal C ouncil to your Library System )
M. TOTAL OTHER EXPENDITURES PAID BY MUNICIPALITY (add lines j to 1) $ -
I , ___________________________________________________________________________________________________________________ , A d m in istra to r
o f , ___________________________________________________________________________________________________________________________________
(name of municipality)
certify th at th e am ou n ts sta ted ab o v e are th e costs in cu rred b y th e m u n icip ality in p ro v id in g th e in d icated ser v ic e s to th e
(name of Library Board)
P rin t N a m e : _________________________________________________________________________________________________________________________
S ign ed : ____________________________________________________________________________________________________________ ;_________________
D a t e : ________________________________________________________________________________________________________________________________
-7-
Page No.0033
Public Library Services Branch Telephone: 780-427-4871
803 Standard Life Centre Fax: 780-415-8594
10405 Jasper Avenue Email: librariesPgov.ab.ca
Edmonton, Alberta T5J 4R7 www.albertalibraries.ca
G overnm ent
2016 APPLICATION FOR FINANCIAL ASSISTANCE for

Municipal and Intermunicipal Library Boards
Application for an annual Library Operating Grant under "The Municipal Affairs Grant Regulation"
(Applicant's name - please print) (Position w ith Board)
O f th e ___________________________________________________________________ L ib ra ry B o a rd
(*Legal name of Library Board)
do solem nly declare th a t I am th e person authorized to receive and disburse funds on behalf o f th e said
Library Board, and th a t I am authorized by the Board to apply fo r the annual grant.
I declare th a t all statem ents made by me on this fo rm are tru e and any funds awarded shall be used solely fo r
lib ra ry purposes. Any funds not used w ill be returned to the G overnm ent o f A lberta, and I make this solemn
declaration conscientiously believing it to be true and know ing th a t it is o f th e same force and effect as if
made under oath and by v irtu e o f the Canada Evidence Act.
{Signature of Applicant) (Date)
*N o te: Please use the LEGAL NAME of the Library Board

as per Section 3(4) of the L ib ra rie s A c t.
Failure to do so will result in the application being returned or delayed.
The personal information that you provide on this form and any attachments will be used for the purpose o f determining your
eligibility for the Public Library Operating Grant program and the prom otion of the program. Your personal information is collected
under the authority of section 33(c) of the Freedom o f In fo rm a tio n a n d P ro te c tio n o f P rivacy A c t (FOIP) and is protected by the
privacy provisions of the Act. If your grant application is approved your name, the grant program and the amount of the grant will
be published on the Government of Alberta Grant Disclosure Portal as authorized in section 40(l)(b) and (f) of the FOIP A ct. Should
you have any questions about the collection, use or disclosure of this information, you may contact Bonnie Gray at 780-415-0295.
If you have any que stion s a b o u t this fo rm o r any p a rt o f th e g ra n t app lica tion , please c o n ta c t M a ri Scott, Grants
A d m in is tra to r at (780)415-0303 o r mari.scottfaigov.ab.ca.

Page No.0034
M unicipal Affairs
This statement is to be submitted by municipal and intermunicipal library boards serving fewer
than 10,000 people. Boards serving more than 10,000 people may submit this form or their own
budget document.
Return the completed and signed budget, a copy of your financial statements (or signed audit),
and your grant application form to:

Public Library Services Branch
803 Standard Life Centre
10405 Jasper Avenue
Edmonton, Alberta T5J 4R7
Phone: (780) 427-4871
Fax: (780)415-8594
mari.scott@gov.ab.ca
Budget requirements in Section 8 of the Libraries Act:
http://www.m unicipalaffairs.alberta.ca/public_iibraryJegislation.cfm
2016 Budget
Budget approved by Library Board as authorized by:
Print Name: ____________________________________ Position:
Signature:
Date: ___
Originals, emailed or faxed copies will now be accepted.

Page No.0035
For Library Board
M unicipal Affairs
- 2 -
Page No.0036
For _Library Board
M unicipal Affairs
ESTIMATE OF EXPENDITURE Budget 2016

Staff
26 Salaries and benefits
27 Honoraria (volunteers)
28 Moving expenses
29 Course or conference fees
30 Travel and hospitality (staff)
31 TOTAL PROJECTED STAFF EXPENSES (add lines 26 to 30)
Library resources
32 Books (include freight and purchased cataloguing; do not include money you transfer to your
library system for book purchases, that info goes on Line 56)
33 Periodicals and newspapers
34 Audio-visual materials
35 Digital and electronic resources
36 TOTAL PROJECTED LIBRARY RESOURCES (add lines 32 to 35)
Administration
37 Audit and/or financial review
38 Board expenses (inel. honoraria, travel, course and conference fees)
39 Equipment rentals and maintenance
40 Legal fees, bank charges, refunds and deposits (inch GST)
41 Library supplies (inch binding & repair)
42 Association memberships (do not include transfer payments to your library system)
43 Postage and box rental
44 Program expense (including publicity/advertising, equipment rental, volunteer appreciation,
artist’s fees)
45 Stationery, printing and copier supplies
46 Telephone and telecommunications, incl. internet connections
47 Other materials and supplies
48 Other expenses
49 TOTAL PROJECTED ADMINISTRATION EXPENSE (add lines 37 to 48)
- 3-
Page No.0037
For Library Hoard
M unicipal Affairs
ESTIMATE OF EXPENDITURE (cont'd) Budget 2016

Building costs \
50 Insurance
5 1 Janitorial and maintenance (janitorial scrvicc/supplies, maintenance and minor repairs to
building and grounds)
52 Utilities
53 Occupancy costs (to municipality)
54 Rent (to private landlord)
55 TOTAL PR O JECTED BUILDING EXPENSES (add lines 50 to 54)
Transfer payments i
56 Transfer to other library boards (please specify boards: may include municipal or library system
boards)
56a
56b
56c
57 Contract payment for library service (e.g., payment to library societies)
57a
57b
58 TOTAL PRO JECTED TRANSFER PAYMENTS (add lines 56 and 57)
59 TOTAL PRO JECTED OPERATING EXPENDITURE (add lines 3 1,36. 49. 55, and 58)
60 Loan interest and payments
61 Transfer to other accounts (i.e., capital, operating reserves)
Capital expenditures
62 Building repairs and renovations (e.g., roof, carpet, partitions)
63 Furniture and equipment
64 Other (please specify)
64a
64b
65 TOTAL PRO JECTED CAPITAL EXPENDITURE (add lines 62 to 64)
66 TOTAL PRO JECTED ESTIM ATE O F EXPENDITURE (add lines 59, 60, 61,65)
Projected cash balance at end of reporting year

67 Cash on hand
68 Total in current bank accounts
69 Total in savings accounts
70 Term deposits
7 1 Other committed funds (e.g. trusts and bequests, reserves, capita!)
72 TOTAL PRO JECTED CASH ON HAND (add lines 67 to 71)
73 TOTAL PRO JECTED CASH ACCOUNTED FOR (add lines 66 and 72)
Please continue on to Page 5 if your Municipality will make any payments on behalf of the Library Board.
Please have the Municipal Administrator fill out this form.
-4-
Page No.0038
For Library Board
ÂilaeyrbcyM M unicipal Affairs
Direct Payments
If it is anticipated that the municipality will pay costs in addition to its local appropriation to the library board, this page
should be completed by a municipal administrator. Include only that portion of the municipal expenditure that is paid on
behalf of the library board. The figures in lines a to m should not be included by the library board’s Budget.
OPERATING EXPENDITURES TO BE PAID BY MUNICIPALITY (DIRECT Budget 2016

PAYMENTS)
1 1
a. Staff (salaries and benefits, moving expenses, course fees)
b. Building maintenance (janitor, supplies, maintenance, and repairs)
c. Insurance
d. Utilities
e. Audit
f. Rent (to private landlord)
g. Telephone
h. Other expenses
I. TOTAL PROJECTED OPERATING EXPENDITURES TO BE PAID BY MUNICIPALITY
(add lines a to h) $ -
|Other expenditures to he paid by municipality j
j. Debenture interest and principal
k. Capital or special grants (one-time grants)
1. Library System appropriation (contribution of your municipal council to your library system)
M. TOTAL PROJECTED "OTHER" EXPENDITURES TO BE PAID BY MUNICIPALITY
(add lines j to 1) $ -
I ,_________________________________________________________________________________________________ , Administrator
o f,______________________________________________________________________________________________________________
(name of municipality)
certify (hat the amounts stated above are the costs incurred by (he municipality in providing the indicated services to the
(name of Library Board)
Print Name:
Signed: ___
Date:____
-5 -
Page No.0039
Municipal Affairs
2016
Minister’s Awards for Excellence
in Public Library Service
Nomination Package

Page No.0040
2016
Minister's Awards for Excellence in Public Library Service
The Minister’s Awards for Excellence in Public Library Service encourages, recognizes
and applauds excellence and innovation in public library service in Alberta.
Aw ard Rules*:
Alberta public libraries, who meet the following criteria, are eligible for a Minister’s
Award for Excellence in Public Library Service:
• Awards are open to all public library boards and regional library system boards in
Alberta.
• Awards are granted to the board of the library or system delivering the service
being recognized.
• Award nominations will be reviewed by an awards committee.
• Any photos submitted may be used for promotional purposes (e.g. website).
• All nominations received that meet the Minister’s Awards criteria will
automatically be eligible for the YOU Libraries Award. A separate nomination
form is not required.
Nom ination C hecklist
Completed Nomination Form;
Completed Critical Information (detailed responses to the requested points one

through seven in a separate attachment.
F re e d o m o f In fo rm a tio n a n d P ro te c tio n o f P riv a c y A c t (F O IP )

The personal information that is provided in the nomination submission about the nominee is collected
under the authority of section 33(c) of the F re e d o m o f In fo rm a tio n a n d P ro te c tio n o f P riv a c y A c t and is
protected by the privacy provisions of that Act. The information will be used for the purpose of
administering the Minister’s Awards for Excellence in Public Library Service program and to select and
publicize the achievements of the award recipients.
DEADLINE FOR NOM INATIONS:

MARCH 11, 2016
The winners will be notified in writing of the selection committee’s decision at the
beginning of April 2016.
* Full rules available at www.albertalibraries.ca
Page 2 of 4
Page No.0041
2016
Government Minister’s Awards for Excellence in
Public Library Service
Nomination Form
L ib r a r y B o a r d
N am e
L ib r a r y C o n t a c t
F ir s t N a m e Last N am e
T it le
Phone E m a il
N o m in a t o r
F ir s t N a m e Last N am e
E m a il
Critical Information:
1. Describe the library service under consideration for the award.
2. What were the goals, objectives and/or desired outcomes of this service?
3. What were the actual results of the service? (Include available measurements of
success such as the use of statistics.)
4. What makes the service excellent and/or innovative?
5. How does this service fit into the library’s plan of service?
6. What community need did this service meet? How was this need determined?
7. Additional information (Attach photos and/or letters of recommendation for this
program).
F u ll r u le s a r e a v a ila b le a t:
w w w .a l b e r t a l ib r a r ie s .c a
F o r m s a n d a n y o t h e r in f o r m a t io n c a n b e e m a ile d to :
K a r e n P e t c h a t lib r a r ie s @ q o v .a b .c a
W ith t h e s u b je c t lin e “ M in is t e r ’s A w a r d s N o m in a t io n ”
O R m a il h a r d c o p y to :
A lb e r t a M u n ic ip a l A f f a ir s , P u b lic L ib r a r y S e r v ic e s B r a n c h
8 0 3 , S t a n d a r d L ife C e n t r e , 1 0 4 0 5 J a s p e r A v e n u e , E d m o n t o n A B T5J 4R7
Page 3 of 4

Page No.0042
2016
Government M in is t e r ’s A w a r d s f o r E x c e lle n c e in
P u b lic L ib r a r y S e r v ic e
Tip Sheet
Provided below are some additional points to consider when completing the C ritic a l
section of the nomination.
In fo r m a tio n
o identification of partners in the service.

■ What was their role, how did they participate?
■ How did all partners benefit?
o What community need did this service meet? How was need determined?
■ Evidence from plan of service/needs assessment.
* Usage or uptake of the new service.
- How were library users made aware of the new service?
- Statistics: number of users and who they are.
- Did this service attract new library users?
o How could this service work in other libraries?

■ Are you able to share this service with other libraries?
o What were the lessons learned in developing this service?

■ If you were to do it again, what changes wouid you make, in approach or in
implementation?
o The nomination may be accompanied by other supporting materials relating

directly to the service under consideration.
Page 4 of 4

Page No.0043
Municipal Affairs
R e q u e s t F o r F l e x ib l e W ork A rrangem ent

Employee Name:
Employee Num ber:
W o rk U nit/B ranch/D ivision:
W orking Title:
Check ONE:
Bargaining Unit Opted Out/Excluded Management
Part I: to be Completed by the Employee
I would like to request the following flexible work arrangement:
___ Flex Day ___ Modified Hours ____ Part-Time

Please refer to the Flexible W ork A rrangem ents Guiding Principles and Options.
____ Job-Share
Please refer to The Job Share Guidebook fo r Employees and Supervisors
To request Telework, do not use this form. Please complete the Request fo r T elew ork
A rra n g e m e n t. Refer to the Telework Guidelines fo r m ore inform a tion .
1. Proposed hours o f w ork:
2. Explanation o f how service and p ro d u c tiv ity is to be m aintained:
3. Id en tify any challenges th a t m ight arise as a result o f you participating in a Flexible W ork
Arrangem ent. Provide solutions to any p ote n tia l drawback.
4. How w ill you handle regular com m unications w ith clients, co-workers, supervisors to
m aintain accessibility and quality?
Page 1 o f 2

Page No.0044
Government of Alberta u
Municipal Affairs
R e q u e s t F o r F l e x ib l e W o r k A r r a n g e m e n t
5. W hat support w ilt you need from team m em bers to m eet operational requirem ents?
I understand and agree that:

• This request accurately represents my situation and has been discussed w ith my team .
• This arrangem ent is subject to governing policies, Collective Agreem ent and principles in
the Flexible W ork Arrangem ents Guiding Principles and Options.
• This arrangem ent is to be reviewed on a regular basis to ensure operational requirem ents
are being achieved and th a t service levels are m aintained.
• If this arrangem ent does not result in satisfactory service to the public, or is deemed to be
unsuitable fo r o th e r reasons, fo r example, business needs change or perform ance issues
arise, notice can be provided by e ithe r p arty to return to norm al hours o f work.
Employee Signature: Date:
Please forward request with any necessary attachments/ agreements for approval.
Part 2: Approvals
Im plem entation
D ate/C om m ents:
Supervisor: Date:
Branch Head: Date:
Executive Team M em ber: Date:
cc: Human Resource Services / Employee File
Page 2 o f 2

Page No.0045
Government of Alberta
Municipal Affairs
Request For T elework A rrangement
Employee Name:
Employee Number:
W o rk U nit/B ranch/D ivision:
W orking Title:
Check ONE:
Bargaining Unit | Opted Out/Excluded Management
Part I: To be Completed by the Employee
Please re fe r to th e Guiding Principles fo r Flexible Arrangements.
I would like to request a Telework arrangement:
Please refer to th e Telecom m uting Guidelines and attach com pleted te lecom m uting agreem ent
and hom e-safety checklist w ith yo u r request.
1. Explanation o f how service and p ro d u ctivity is to be m aintained:
2. Identify any challenges th a t m ight arise as a result o f you participating in a Telew ork
Arrangem ent. Provide solutions to any p ote n tia l drawback.
3. How w ill you handle regular com m unications w ith clients, co-workers, supervisors to
Page 1 o f 2

Page No.0046
Request For T elework A rrangement
I understand and agree that:
• This request accurately represents my situation and has been discussed w ith m y team .
• This arrangem ent is subject to governing policies, Collective Agreem ent and principles in
the Telework Guidelines.
• This arrangem ent is to be reviewed on a regular basis to ensure operational requirem ents
are being achieved and th a t service levels are m aintained.
• If this arrangem ent does not result in satisfactory service to the public, or is deem ed to be
unsuitable fo r o th e r reasons, fo r example, business needs change or perform ance issues
arise, notice can be provided by e ithe r party to return to norm al hours o f w ork.
Please forward request with together with a completed telework agreement and home office
safety checklist for approval.
Part 2: Approvals
Innplementation
Date/Com m ents: ____________________________________________________
Supervisor: Date:
Executive Director: Date:
Assistant Deputy M inister: ________________________ Date:
cc: Human Resource Services / Employee File
Page 2 o f 2

Page No.0047
Municipal Affairs
A p p lic a tio n fo r D e v e lo p m e n t In itia tiv e

EMPLOYEE’S PROPOSAL
Employee Name: Employee Number:

Workinq Title:
Phone No.:
Branch:
Division:
Date Request Initiated:
Purpose of Application
Financial Support for Development Educational Leave
NOTE: Expand each field as needed
Description of Proposal
Program of study_ (please attach description of program)
Program objective
Name and location of institution
Timeframe for course completion
Type of studies (part-time, evenings, etc.)
Proposed Start and Completion dates:__
Number of work days absent: _________
Will completion of the program require out of province travel ______ Yes ______ No
If yes, please include a “Out of Province/Country Travel Authorization" form in your application to obtain DM approval.
Anticipated Costs
Estimated Costs Amount of Support Amount Percent
Requested Paid by Carried by
Employee Employ
Tuition
Books
Travel (if required to travel outside of city of
residence)
Accommodations
Other:
If Education Leave
- Current Gross Salary for Education
Leave Period
Total Anticipated Costs for Program $ $
Created March 2014 Page 1 of 4

Page No.0048
Operational Considerations - Employee/Supervisor’s plan to manage workload/studies:
Qualifications and Contribution to the Ministry
Describe some of your past contributions to Municipal Affairs or other government ministries (significant
accomplishments, projects, etc.)
How will the program of study build on these experiences?
Compatibility of Development with the Ministry’s Goals and Priorities
Describe how the development is compatible with Municipal Affairs’ business needs. Please include reference to the
A PS Competencies. The following questions m ay assist with this assessment:
1. W hat skills, competencies or subject matter expertise will be developed?
2. How do they fit forecasted human resource requirements and succession plans for Municipal Affairs or for other
ministries within the Government of Alberta?
3. How will you apply the skills, competencies or subject matter expertise in your current role? In potential future roles?
Benefit to the Ministry and/or the Government of Alberta

In the longer term, how you see the learning from this program will benefit Municipal Affairs.
How will you transfer knowledge of your learning back to the workplace? (e.g., presentations; mentoring another
employee, article in the Connector, etc.) I f th is p ro p o s a l is s u p p o rte d , k n o w le d g e tra n s fe r a c tiv itie s w ill b e b u ilt in to y o u r
c a re e r a n d le a rn in g p la n a s p a r t o f P e rfo rm a n c e E x c e lle n c e .
Summary of Request
Based on the information provided above, I am requesting financial support fo r ___ % of the estimated costs which
equals $_________________ . Additionally,________ work days are needed to attend classes or to write exams. I intend
to use my earned vacation, management supplement, and special leave* as approved by my supervisor.
*Note: up to 10 days Special Leave can only be used fo r writing exam inations - see Collective A greem ent A rticle 38.01 (f)
A TTA C H M EN TS:
• Description and schedule of costs for program of study
• Completed Appendix A - Return Service Agreement for requests of more than $5,000 or more.
• If out of province travel is requested, an O u t o f P ro v in c e /C o u n trv T ra v e l A u th o riz a tio n form
SIGNATURE
Employee’s Signature Date
Page 2 of 4

Page No.0049
SUPERVISOR’S COMMENTS ASSESSMENT OF REQUEST
Please provide relevant comments relative to the request such as: employee's ongoing performance; implications for
the business area, recommendations on cover-off when employee is away from the workplace; how this development
aligns with the ministry’s goals and business plan; is there sufficient funding available for this request.
Assess Request for Support:
1. Human Resource Requirement (maximum of 50%) Recommendation: ____ %

Some questions to consider:
• How closely does this proposal fit forecasted ministry/government human resource requirements?
• Can the ministry ensure that the employee’s current duties are performed by alternate resources during the
person’s absence?
• How soon will the benefit of the initiative be realized?
2. Employee’s Contribution to the Ministry (maximum of 30%) Recommendation: ____%

• Has the employee’s performance over past years been satisfactory?
• Has the employee demonstrated versatility and individual initiative in pursuing career development that is
consistent with organization needs?
• Has the employee achieved any major accomplishments that have had an impact on the ministry’s business
plan or the overall achievements of the ministry?
3. Nature of Proposed Initiative (maximum of 20%) Recommendation: ____ %

• Is the proposed program the closest, most economical and convenient choice of resources available to
achieve the desired outcomes for the employee?
• Is there a sound correlation between this proposal, the needs of the ministry or the GoA and the employee’s
career plan?
• What is the likelihood of the proposed workforce development initiative achieving the desired results?
Financial assistance based on the nature of the proposed initiative:

Degree___________________ Low_________ Medium____________ High
Percentage of Support 5% 10% 15% 20%
Page 3 of 4

Page No.0050
Consultation with Human Resources Completed
Consultant Initials Date
SUPERVISOR’S RECOMMENDATION
Total Cost of Financial Assistance to be funded by Ministry $___________
Percent of Cost for the Development to be funded by Ministry ___________ %
Total number of work days not funded by employee through vacation, flex-days or other: ___________ days
Return Service Commitment* (Appendix A): □ Draft Completed and Attached* □ Not Recommended
*Note: W hen Ministry support equals $ 5,000 or more, a return service agreement is typically required. Requested
support is $ 5,000 or more and a return service agreement is not recommended, please provide rationale below:
Supervisor’s Signature Date
Please refer to Alberta Municipal Affairs Human Resource Services Delegated Authorities
MANAGER/DIRECTOR:
Comments and Recommendations:
Manager/Director Signature Date
Expenditure Officer Signature (If other than above) Date
EXECUTIVE TEAM MEMBER:

Comments and Decision/Recommendation
Executive Team Mem ber Signature Date
DEPUTY MINISTER (If Required)

Comments and Decision
Deputy Minister Signature Date
Page 4 of 4

Page No.0051
Authorization for
Municipal Affairs Staff Development
Course Information
Course/Conference Title
Address City
Sponsor/Supplier
Start Date (m m /dd/yyyy) End Date (m m /dd/yyyy) Workdays Absent
Estimated Costs $ $ $ $
(Employee) (Tuition) (Travel) (Other) (Total)
Business Unit Fund Code Program Code Dept ID Account Code
Rationale for Request (provide the rationale to support approval of this request)
Priority
I I Directly Related to Job________ I I Approved Development Priorities_______I I Ongoing Development/Currency within Profession
Employee Signature Date
Supervisor Date
Note: Please refer to the Delegated
Authority for Human Resources,
Branch Director Date
Section 15/Staff Development for the
necessary approvals.
Assistant Deputy Minister (if required) Date
Deputy Minister (if required) Date
Actual Costs
$ $ $ $
(Financial Op.) (Tuition) (Travel) (Other) (Total)
Note: 1. The Original signed form must be attached to the invoice and forwarded to Finance.
2. Copy of form to be forwarded to Human Resource Services.
H R M A 0506 (2008/05) Alberta Municipal Affairs Information Request 2015-R-0088

Page No.0052
Government of Alberta EMPLOYEE TERMINATION/
Municipal Affairs TRANSFER/LEAVE CHECKLIST
Please complete the following and send completed form to HR Services. Submit resignation letter, notice o f retirem ent or transfer
documents to HR Services.
□ T E R M IN A T IO N □ TRANSFER TO _____ □ MATERNITY □ OTHER _____

(Leaving GoA) M inistry or Division (Secondment, Leave w ith out Pay, LTDI,
E m p lo y e e N am e E m p lo y e e ID n u m b e r D e p a rtu re /T ra n s fe r D a te
D iv is io n /B ra n c h S u p e rv is o r N a m e S u p e rv is o r T e le p h o n e N u m b e r
A. EMPLOYEE BRANCH/DIVISION
Prior to Departure: Supervisor/ Manager/Employee fo inform concerned units regarding resignation/transfer/leave Yes N/A
of absence________________________________
1, Send email Finance.checklist(5)gov.ab.ca □ □
2. Cancel P-card > Complete form P-Card change request send to Finance.checklistta'Eov-ab.ca □ □
Pate of Departure:
W ill the follow ing be accounted for/return ed? Yes N/A W ill the follow ing be accounted for/returned? Yes N/A
(Employee to Fill out this section) (Monager/Supervisor tofill out this section then to Branch SRC)
Complete final tim esheet □ □ Assets, attractive items

u u
Return all records-electronic and printed □ □ Wireless Devices (i.e. IPad, IPhone, BlackBerry) □ □
Proper materials are removed from desk/computer
□ □ Wireless Devices transferred/cancelled
U □
GoA ID Card Returned □ □ Parking card. Decal, Security Access card. Keys, USB, CDs
□ □
Security Access Card returned □ □ 8ranch staff contact inform ation updated?
□ □
P card returned □ □ IT Hardware returned
□ □
Keys returned □ □ First Aid Kit Returned?
□ □
W ork related documents retrieved □ □ Time Approver access removed?
□ □
Terminate employee in IMAGIS □ □
Voice mail password reset
□ □
MDM Service Request
□ □
Employee Date Branch Manager/Director Date
PLEASE FORWARD THE COMPLETED SIGNED FORM TO THE NEXT BRANCH LISTED AS SOON AS POSSIBLE
B, INFORMATION MANAGEMENT, LEGISLATIVE & ADMIN C. INFORMATION TECHNOLOGY SERVICES
SERVICES (Facility Coordinator) (IT A dm inistrator)
W ill the follow ing be returned/done? Yes N/A Will the follow ing be returned/done? Yes N/A
GoA Directory Updated □ □ Terminated Computer User ID Verified (Network) u u

Parking Card □ □ Citrix FOB Returned □ □
Parking canceled □ □
Security Access Card No. □ □
Security access canceled □ □
Manager, Inform ation Management & Adm inistrative Services Date Director, Inform ation Technology Services Date
D. FINANCIAL SERVICES Yes N/A

(Executive Assistant to the SFO)
Procurement Card returned? M i_J COMMENTS
Expenditure/Accounting Officer A uthority Cancelled j_i i J
Procurement Card inactivated in IMAGIS? □ □
IMAGIS I.D. au thority cancelled w ith IBM? Q [__|
Inactivated user in EXCLAIM? □ □
Director, Financial Operations and Accountability Date
SUBMIT COMPLETED FORM TO HUM AN RESOURCE SERVICES

The information on this form is being collected and will be managed in compliance with the Freedom of Information and Protection of Privacp j |ge No nn53
EMPLOYEE TERMINATION/TRANSFER/LEAVE CHECKLIST FORM
INSTRUCTIONS GUIDE
Definitions
• Term ination: leaving the Government o f Alberta

■ Transfer To: moving from one ministry to another ministry or staying w ith the same ministry but changing divisions
■ M aternity: leave of absence due to childbirth
■ Secondment: accepting another position w ithin their current ministry or with another ministry on a temporary basis fo r a
specific period of time
Leave W ith o ut Pay: a period of tim e away from work for which an employee is not paid
■ Long Term Disability Income: a medical condition that causes an employee to be unable to perform their regular duties
and be away from work for a period of time
* Parental leave: leave of absence granted to an employee to care fo r their baby or child
Step by Step Instructions for each field______________________________________

1. Reason: Termination, Transfer To, M aternity or Other (if Other, w rite specific reason)
2. Employee name and ID number
3. Departure Date: effective date of resignation or the day following the last day paid
Transfer Date: effective date of transfer or first day of work to the new position_____
4. Division/Branch or Unit_____________________________________________________
5. Supervisor name and telephone number______________________________________
Part A - Employee Branch/Division: To be completed by the Supervisor/Manager and Employee____________________________

1. Send an email to (Finance.checkii5t@gov.ab.ca) to inform Finance of resignation/transfer/ leave of absence
Sample email:
Resignation: This is to inform you that "Employee" is resigning from the Government o f Alberta effective "date". Employee will be
taking vacation from - to (if requested).
Transfer: This is to inform you that "Employee" will transfer to "M inistry" or "Division w ithin the departm ent" effective "date".
Maternity: This is to inform you that "Employee" will be on m aternity leave effective "date".
Secondment: This is to inform you th a t employee will be on secondment to "M inistry" effective "date" to "date".
LTD! - This is to inform you th a t employee is now on LTDI effective "date".________________________________________________
2. Cancellation of P-card: Supervisor/manager to complete the P-card change request form and send to
Finance.checkiist@gov.ab.ca mailbox. Check o ff N/A if employee does not have a P-card.________________________________
3. Date of Departure: Physical last day of work______________________________________________________________________
4. Employee to check off items and sign it. Once completed, employee will return all items as indicated to supervisor/manager.
5. Supervisor/Manager to check off items received from the employee and signs it. Once completed, the form and items are
returned to the Branch Service Request Coordinator (SRC).
The Branch SRC to fulfill their responsibility as SRC. Once completed, the Branch SRC forwards the form to the next branch,
Information Management, Legislative & Administrative Services (IMLAS).____________________
Part B - Facility Services

To be completed by the Facility Coordinator and signed by the Manager, Inform ation Management & Administrative Services.
Once completed, the Facility Coordinator will forward the form to the next branch, Inform ation Technology Services.________
Part C - Information Technology Services

To be completed by the IT Adm inistrator and signed by the Director, Information Tech Services. Once completed, IT Administrator
forwards the form to Financial Services.
Part D - Financial Services

To be completed by the Executive Assistant to the SFO and signed by the Director, Financial Policy & Accountability. Once
completed, Executive Assistant forwards the form to Human Resource Services.
Human Resource Services will retain a copy for their files and audit purposes then send the completed form to Service Alberta, Client
Services Operations (Payroll).

Page No.0054
ji First Aid Record
NOTE: If completing by hand, add returns to fields that require additional space before printing this document.
INSTRUCTIONS
The First Aider completes Sections A and B and submits the record to:
1. the injured employee’s supervisor.
The Supervisor completes Section C, and
1. reviews the completed record with the manager
2. retains the completed record in a confidential file at the workplace for at least three years from the date of injury
or illness.
SECTION A Injury or Illness Reported

Name of Employee Date (yyyy/mm/dd) Time (24 hr clock)
Department Workplace and Address
SECTIO N B
Name of First Aider D escription of First Aid Provided
Qualifications of First Aider

I I Emergency EH Standard EH Advanced EH Nurse EH Emergency Medical Responder
I I Emergency Medical Technician - Paramedic EH Emergency Medical Technician - Ambulance
Signature of First Aider Date (yyyy/mm/dd)
SECTION C
Injury Sustained or Illness Started
Date (yyyy/mm/dd) Time (24 hr clock)
Describe Injury or Illness
How did Injury or Illness Occur
Was Medical Aid Required? Was a copy of this report requested and provided to the employee?
I—I ^ es I—I EH Yes EH No If Yes, have employee initial________
Cause of Injury or Illness
Corrective Actions
Signature of Supervisor Name of Supervisor (PRINT) Date (yyyy/mm/ddj
Signature of Manager Name of Manager (PRINT) Date (yyyy/mm/dd)
WPH0004 (2012/06) Page 1 of 1

Page No.0055
Workplace Near Miss
_____ Incident Report
INSTRUCTIONS
The Employee completes Part 1 and submits the report to the supervisor.
The Supervisor completes Part 2 and submits the report to the manager.
The Manager
1. Completes Part 3 and retains a copy at the workplace.
2. Ensure boxes indicating signed original retained at the workplace are checked.
3. Sends completed report to:
• Service Alberta, WCB Administration
Email: nearmiss.reports@qov.ab.ca
• Service Alberta will not enter this report if the boxes have not been checked.
4. Sends a copy of the completed report to:
• Department Human Resource Services. ____ _________
PART 1 - DETAIL REPORTING INFORMATION

Name of Employee Employee Number Employee Status
(7 digits)
1 1 Salary Q Contract
Job Title
1 i Wage Q Other
Department Department I.D. Number

(7 digits)
Division / Branch
INCIDENT DETAILS
Date Time S pecific Location of Incident (area within a building, nearest town or city, street address OR
(yyyy/mm/dd) (24 hr clock) Land- Section-Division, individual's home, community, residential care, etc ■)
Describe the factors leading up to the incident, the staff involved and the task performed.
What happened? Why did it happen? How did it happen?
Describe the Potential Injury / Loss
TYPE OF NEAR MISS

I I Verbal Threat Q Physical Threat Q Vehicle Use Q Equipment Use Q Environment O Property
I i Other
Signature of Employee Date (yyyy/mm/dd)
I I Signed original retained at workplace.
WPH0002 (2012/06) Page 1 of 2

Page No.0056
Workplace Near Miss Incident Report
PART 2 -SUPERVISOR
Was a Hazard Assessment and Control Report completed for the task before the incident? □ Yes Q No
CORRECTIVE ACTION(S)
Action Person Responsible Completion Date
Signature of Supervisor Name of Supervisor (PRINT) Date (yyyy/mm/dd)
PART 3 - REVIEWING MANAGER

Comments
Have changes been made to the Hazard Assessment and Control Report as a result of this incident?
I I Yes □ No O Not Required
WPH0002 (2012/06) Page 2 of 2

Page No.0057
y&ib&rbfcJi Witness Statement
INSTRUCTIONS
The Investigator
1. has the witness LEGIBLY complete the Witness Information, including the Statement
2. completes the Questions and Answers, during the interview with the witness, and the Investigator information
3. retains a copy of the completed statement
4. attaches the completed Witness Statement to the “Serious Incident, Fatality and Radiation Investigation Report"
and submits them together to the manager.
WITNESS INFORMATION
Date of Birth Telephone Number
Name (yyyy/mm/dd) (include area code)
Occupation / Job Title
Department / Employer Address of Department / Employer
Relevant Length and Type of Experience with the Department / Employer
Other Length and Type of Relevant Experience
Task Being Performed at the Time of the Incident
Statement
QUESTIONS and ANSWERS

Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
WPH0006 (2012/06) Page 1 of 2

Page No.0058
Witness Statement
Signature of Witness Providing the Statement Date (yyyy/mm/dd)
INVESTIGATOR TAKING THE STATEMENT

Name Job Title Telephone Number
(include area code)
Department Workplace and Address
Signature of Investigator Taking the Statement Date (yyyy/mm/dd)
W PH0006 (2012/06) Page 2 of 2

Page No.0059
Supervisor’s Incident
yiib&rbcai Investigation Report
INSTRUCTIONS
The injured employee’s Supervisor
1. completes Part 1 through 4 of the report
2. has the injured employee complete Part 5
3. submits the report to the manager.
The Manager
1. reviews the report and completes Part 6
2. retains a copy of the completed report at the workplace
3. sends the completed report to:
• Service Alberta, WCB Administration - Fax: 780-644-5747
4. sends a copy of the completed report to:
• Department Human Resource Services.
PART 1 - DETAIL REPORTING INFORMATION

Name of Employee Employee Number Employee Status
(7 digits)
EH Salary EH Contract
Job Title
EH Wage EH Other
Department Department l.D . Number (7 digits)
Division / Branch
TYPE EH Medical Aid EH Lost Time EH Fatality
I I Personal Property Damage ( I f p e r s o n a l p r o p e r ty d a m a g e is c h e c k e d , d o N O T c o m p le te a re a s A , B o r C b e lo w .)
Was a Hazard Assessment and Control Report completed for the task before the incident? □ Yes EH No
Employee's experience in present job? EH Less than 1 year EH More than 1 year
PART 2 - OCCURRENCE DETAILS

incident Occurred______________ Incident Reported
Date Time Date Time
(yyyy/mm/dd) (24 hr clock)
Reported To Reported By
(yyyy/mm/dd) (24 hr clock)
Describe the Incident or Illness (include the activity that was being performed at the time of the incident)
Location of Incident (Building, Street Address and City/Town OR Land-Section-Division and nearest CityTTown)
WPH0001 (2012/06) Page 1 of 4

Page No.0060
Supervisor’s Incident Investigation Report K
Name of Witness(es) Telephone Number (include area code)
Has a report been submitted to the Workers' Compensation Board? EH Yes EH No
A. BODY PART INJURED

Check appropriate boxes and circle the prim ary injury
i 1abdomen 1 1ankle(s) □ arm(s) 1 I back 1 I buttocks/tailbone 1 1chest/ribs EH ear(s)
[ 1elbow(s) □ eye(s) 1 1face 1 1finger(s) 1 1foot/feet 1 I groin EH hand(s)
1 1head □ hip(s) 1 1internal 1 1knee(s) □ leg(s) 1 1lungs EH neck
1 1shoulder(s) □ toe(s) 1 1 undetermined medical 1 1wrist(s)
B. NATURE OF INJURY/ILLNESS
I I multiple injuries - check this box only

OR proceed by checking one box only below.
EH abrasion EH allergic reaction □ amputation EH bruise EH burn

|_| concussion 1 1disease □ electric shock EH emotionai/psychological EH foreign body-eye
|_| fracture |_| frostbite □ hearing loss EH heat stress H ] hernia
EH hypothermia EH incision/cut □ poisoned EH puncture EH respiratory
|_[ skin condition |_| sprain (joints) □ strain (muscles) EH tooth damage EH undetermined medical
|_| welding flash irritation |_| whiplash
C. SOURCE OF INJURY
Check one box only TYPE
EH animal/insect EH body mechanics EH vegetation
|_| climatic condition EH chemical substance EH machinery
|_| computer use |_| facility/furnishings | HI materials/
□ ground/floor/terrain □ human (non-client) objects
EH human (client) □ lifting |_| tools
EH over exertion EH personal lifts/elevators |_| vehicle
1~~l other
D. INCIDENT TYPE
Check one box only
EH bites/stings EH bodily reaction EH caught in/under/between EH contact with electrical current

HI contact extreme HI exposure to harmful substance lH] fall from elevation | HI fall-on same level
temperature
HI penetrated EH radiation EH rubbed/scraped
EH noise exposure
EH struck by EH vehicles EH verbal/physical assault
EH struck against
WPH0001 (2012/06) Page 2 of 4

Page No.0061
Supervisor’s Incident Investigation Report
E. ACTIVITY BEING PERFORMED AT TIME OF INCIDENT

Check one box only
1 1animal/agriculture [" I client care 1 1construction 1 1correctional

1 1demolition 1 Idrivina 1 1fire operations 1 1food services
1 1hand tools 1 1heavy equipment operation 1 1inspection/enforcement 1 1instruction/training
n janitorial 1 1laboratory 1 1maintenance/repair 1 1materials handling
1 1office work 1 1physical conditioning 1 1power tools 1 1recreation
1 1sampling/monitoring 1 1social services I 1surveying 1 1travel (non-driving)
PART 3 - DIRECT CAUSES

Check the appropriate box(es)
HAZARDOUS ACTS HAZARDOUS CONDITIONS
f~l failure to follow procedure I 1failure to use PPE 1 1defective tools, equipment, materials I~1 chemical/biohazards
1 1failure to warn/secure 1 1improper lifting 1 1inadequate/improper guards/barriers I~1 noise
1 1operate at improper speed I~1 removing safety devices 1 1inadequate or improper procedures 1 1poor housekeeping
1 1use defective equipment 1 1violence threats 1 1inadequate/improper PPE d poor visibility
1 1other 1 1other
PART 4 - CONTRIBUTING FACTORS

Check the appropriate box(es)
I~1 behaviours d engineering I I knowledge/skill d other
I I leadership/supervision d maintenance □ mental stress
I I purchasing d physical stress I I physical capability
Have immediate notification requirements been completed? d Yes d No
Signature of Supervisor Name of Supervisor (PRINT) Date (yyyy/mm/dd)
W PH0001 (2012/06) Page 3 of 4

Page No.0062
Supervisor’s Incident Investigation Report
NOTE: This section is not completed for a fatality.

PART 5 - STATEMENT OF INJURED EMPLOYEE
Statement
Has this condition developed over time? EH Yes EH No

Is this a recurrence of a previous injury? EH Yes Q No If Yes, complete the following:
Previous injuries Date(s)
Signature of Employee Name of Employee (PRINT) Date (yyyy/mm/dd)
PART 6 - TO BE COMPLETED BY THE REVIEWING MANAGER
The Corrective Action(s) in Part 3 and 4 are reasonable to prevent reoccurrence of the incident. EH Yes EH No
ADDITIONAL ACTIONS (if applicable)
Have changes been made to the Hazard Assessment and Control Report as a result of this incident?
EH Yes EH No EH Not Required
WPH0001 (2012/06) Page 4 of 4

Page No.0063
Serious Incident, Fatality and
Radiation Investigation Report
NOTE: if completing by hand, add returns to fields that require additional space before printing this document.
INSTRUCTIONS
The Investigator completes this report and submits it to the senior manager. Attach all supporting
The Senior Manager documents, for example:
1. reviews the completed report with the manager • Witness statements
2. retains a copy of the completed report at the workplace • Training documents
3. sends the completed report to: • Maintenance records
* Workplace Health and Safety Contact Centre • Diagrams and
measurements
Telephone: 1-866-415-8690 (Toll-free within Alberta)
Telephone: 780-415-8690 (Edmonton and surrounding area)
• Hazard assessments
Deaf/hard of hearing with TDD/TTY: Telephone: 780-427-9999 in • Laboratory reports
Edmonton and 1-800-232-7215 throughout Alberta. * Engineering reports.
4. sends copies of the completed report to:
• Department Human Resource Services
• Corporate Human Resources - Fax: 780-415-9438
• Alberta Risk Management and Insurance Division - Fax: 780-422-5271.
If any of the areas below are not applicable to the type of incident being reported, write N/A.
TYPE OF INCIDENT Q Serious Incident Q Fatality EH Radiation Incident

INJURED EMPLOYEE
Date of Birth Telephone Number
Name (yyyy/mm/dd) (include area code)
Address
Occupation Work Experience with Employer

months I years
Relevant Experience (if available)
Nature of Injury (brief description of injury sustained)
Severity of Injury (fatal, permanent, disability, medical aid, lost time)
Name of Hospital Employee Taken to Name of Attending Doctor
Next of Kin Information - (in the event of a fatality)

Name Relationship Telephone Number
(include area code)
Address
WPH0003 (2012/06) Page 1 of 2

Page No.0064
Serious Incident, Fatality and
Radiation Investigation Report
EMPLOYER
Department Telephone Number (include area code)
Workplace and Address
PRIME CONTRACTOR - (if two or more employers are involved in work at the same time at the worksite)
Name of Prime Contractor
Address
Name of Supervisor Telephone Number (include area code)
INVESTIGATING POLICE
Name of Officer Name of Police Force Detachment Telephone Number
(include area code)
FIRST AID
Was First Aid Provided? Q Yes [D No If Yes, complete below)
Name of First Aider Describe First Aid Provided Telephone Number

(include area code)
INCIDENT DETAILS
Date Time Location of Incident
(yyyy/mm/dd) (24 hr clock) (Building, Street Address and City/Town OR Land-Section-Division and nearest City/Town)
Detailed Description of Incident
Cause(s) of the Incident
W ere photographs taken? O Yes [ D No If Yes, state how many photos are attached to the report.
CORRECTIVE ACTION PLAN
Action Completion Date

Person Responsible
(ww/mm/dd)
Signature of Manager Nam e of Manager (PRINT) Date (yyyy/mm/dd)
Signature of Senior Manager Name of Senior Manager (PRINT) Date (yyyy/mm/dd)
W P H 0003 (2012/06) Page 2 of 2

Page No.0065
^ ^ lr " N O > K | V " '| M u n icip a l A ffa i
/ n IU A ^ I IvJ and Mousing
FORWARD A COPY OF THIS FORM TO THE SAFETY COORDINATOR
Safety Inspection Report
Name of Branch Location (Floor Number and Building Name) Inspected By
Name of Supervisor Name of Manager Telephone Number Date Inspected
Supervisor's Telephone Number First Aider Name(s) Inspected With [List Name(s)]
AREA(S) INSPECTED:
Area, Building, Equipment, Etc. Unsafe Procedures, Conditions and Corrective Recommendations 0 . H, & S. Reg. Ref. Corrective Action Taken
INSPECTORS COMMENTS:
□ Corrective Action Undertaken As Requested
Signature of Inspector Date
Signature of Person Observing Inspection Date Signature of Manager or Supervisor Date
Signature of Person(s) Accompanying Inspector
Date

M A 0 0 4 7 (1 9 9 9 /0 7 )
Page No.0066
EMERGENCY CONTACT
Em ployee N am e:
Em ployee N um ber:
Business Telephone N um ber: Extension:
Hom e T elephone N um ber:
The fo llo w in g in fo rm atio n is requ ired in th e e v e n t o f an em ergency w h ile

you a re a t w o rk .
N am e, d a y tim e tele p h o n e n um ber and relation sh ip o f tw o people w h o can

be contacted on yo u r behalf.
N am e Phone N u m b er Relationship
The above in fo rm atio n can be updated a t an y tim e by contacting yo u r Pay

and Benefits A d m in is tra to r.
This in fo rm atio n w ill be k e p t co n fid en tial.
Em ployee S ignature: Date:

Page No.0067
Employee ID# Business Unit_____
PERF
Governm ent
Deputy Minister's Performance Plan
for the period
to
Date From Date To
My Name My Department
This plan is intended to help you and your DMEC track your commitments, results and conversations.
For more Information on Performance Excellence, conversation guides and resources, click here.
Part One: My Commitments '
You have already agreed to the commitments in your Perform ance Agreem ent. Use this worksheet to record any additional ones you make
during your conversations with your DMEC or to provide more detail on your core commitments. This Is a living document Add new
commitments as they occur, and note your results as they are completed.
To My Ministry (Based on your business plan goals, supporting the Minister and managing issues.)
f~1 Examples - of commitment statements: 1~1 Conversation Topics - for you and the DMEC to discuss:
My Commitments My Results
{Record any commitment(s) as appropriate.} {What did you achieve? How do you know you've added value?}
To My Corporation (Based on collaboration, pod work, ROFP goals, etc.)

|~1 Examples | | Conversation Topics - for you and the DMEC to discuss:
To My Work Environment (Based on livina our APS values, effective leadership, succession strategies, addressing employee
engagement and providing a quality work environment)
[~1 Examples 1~~| Conversation Topics - for you and the DMEC to discuss:
{Record any commitments) as appropriate.} {What did you achieve? How do you know you've added value?}
To My Career and Learning (Based on competencies, collaboration, teamwork and leadership.)

[~| Examples - of commitment statements: Q Conversation Topics - for you and the DMEC to discuss:
(Mv Development Goal: Knowledae. Skill or A P S C om oetencv to {What did you accomplish? How did you apply what you learned?}
be developed}
{Actlons/Timings: What will you do to meet that goal?}
WDE0001 (2015/07) Page 1 of 2

Page No.0068
Employee ID# Business Unit
PERF
To My Employees (Based on your supervisory responsibilities.)
Examples - of commitment statements: I | Conversation Topics - for you and the DMEC to discuss:
Part Two: Our Conversations

Performance Excellence is an ongoing conversation between you and the DMEC. Sometimes these conversations are short, informal and
spontaneous. Sometimes they are scheduled and focused, to review your contributions, provide constructive feedback and/or discuss your
development needs and plans.
Conversation Topics - examples of topics for you and the DMEC to discuss:
• Your progress in fulfilling your performance commitments.
• Problems you've encountered, how you dealt with them, and what you learned from the experience.
• Key achievements or contributions, how you accomplished them and what you learned from the experience.
• How you can add value through innovation and continuous improvement?
• Issues you're dealing with and how the DMEC can provide support
• Constructive feedback on your demonstrated competencies and development needs.
• Your learning and career goals and how the DMEC can provide support.
Conversation Date Key Discussion Points

{Record key points you want to remember.}
WDE0001 (2015/07) Page 2 of 2

Page No.0069
PERF
Executive Manager on Executive Comm ittee
^4db&rbcyJ* Government Performance Plan
for the period
to
Date From Date To
This plan is intended to help you and your Deputy Minister track your commitments, results and conversations.
Part One: My Commitments
You have already agreed to the commitments in your Performance Agreement Use this worksheet to record any additional ones you make
during your conversations with your Deputy Minister or to provide more detail on your core commitments. This is a living document Add
new commitments as they occur, and note your results as they are completed.
To My Ministry (Based on your business plan goals, supporting the Deputy Minister and managing issues.)
n Examples - of commitment statements: [~1 Conversation Topics - for you and your Deputy Minister to discuss:
To My Corporation (Based on collaboration, pod work, ROFP goals, etc.)

I"! Examples |~| Conversation Topics - for you and your Deputy Minister to discuss:
To My Work Environment (Based on livina our APS values, effective leadership succession strateaies. addressina emolovee
engagement and providing a quality work environment.)
n Examples |~1 Conversation Topics - for you and your Deputy Minister to discuss:
To My Career and Learning (Based on competencies, collaboration, teamwork and leadership.)

I"! Examples - of commitment statements: | |Conversation Topics - for you and your Deputy Minister to discuss:
{Mv Develooment Goal: Knowledae. Skill or A P S Com Detencv to {What did you accomplish? How did you apply what you learned?}
be developed}
{Actions/Timings: What will you do to meet that goal?}
WDE0001 (2015/07) Page 1 of 2

Page No.0070
------------------- PERF
To My Employees (Based on your supervisory responsibilities.)
i~l Examples - of commitment statements: [~1 Conversation Topics - for you and your Deputy Minister to discuss:
{Record any commitments) as appropriate.) {What did you achieve? How do you know you've added value?)

Performance Excellence is an ongoing conversation between you and your Deputy Minister. Sometimes these conversations are short,
informal and spontaneous. Sometimes they are scheduled and focused, to review your contributions, provide constructive feedback and/or
discuss your development needs and plans.
Conversation Topics - examples of topics for you and your Deputy Minister to discuss:
• Issues you're dealing with and how your Deputy Minister can provide support.
• Your learning and career goals and how your Deputy Minister can provide support.

{Record key points you want to remember.)
WDE0001 (2015/07) Page 2 of 2

Page No.0071
Employee ID# Business Unit______
PERF
y&iherbfij* Government My Performance Plan

for the period
to
Date From Date To
This plan is intended to help you and your supervisor track your commitments, results and conversations. It will not
be placed on your employee file unless specifically requested by you and/or your supervisor.
You have already agreed to the commitments in your Performance Agreement Use this worksheet to record any additional details of the
commitments you make during your conversations with your supervisor. This is a living document Add new commitments as they occur,
and note your results as they are completed.
To My Job (Based on your job responsibilities and your area's operational plan.)
i~1 Examples - of commitment statements: [~| Conversation Topics - for you and your supervisor to discuss:
To My Branch, Division, Department (Based on collaboration and teamwork.)

|~~1 Examples - of commitment statements: |~1 Conversation Topics - for you and your supervisor to discuss:
{Record any commitment(s) as appropriate.) {What did you achieve? How do you know you've added value?)
To My Work Environment (Based on living our APS values and contributing to a positive work environment)
□ Examples - of commitment statements: [~1 Conversation Topics - for you and your supervisor to discuss:
To My Career and Learning (When developing your Career and Learning commitments, focus on your learning needs to enhance
performance in your current role and/or actions to prepare you for longer-term career opportunities.) Click here to access resources to
help you develop your plan.
[~| Examples - of commitment statements: I | Conversation Topics - for you and your supervisor to discuss:
fMv Development Goal: Knowtedae. Skill or APS Comoetency to {What did you accomplish? How did you apply what you learned?)
be developed)
{Actions/Timings: What will you do to meet that goal?)
WDE0001 (2015/07) Page 1 o f2

Page No.0072
------------------- PERF
To My Employees (for those who supervise others) (Based on your supervisory responsibilities.)
|~~1 Examples - of commitment statements: I | Conversation Topics - for you and your supervisor to discuss:

Performance management is an ongoing conversation between you and your supervisor. Sometimes these conversations are short,
informal and spontaneous. Sometimes they are scheduled and focused, to review your contributions, provide constructive feedback and/or
discuss your development needs and plans.
Conversation Topics - examples of topics for you and your supervisor to discuss:
• Issues you're dealing with and how your supervisor can provide support.
• Your learning and career goals and how your supervisor can provide support.

{Record key points you want to remember. This is your space - you and your supervisor can decide whether to
write a lot or a little.}
WDE0001 (2015/07) Page 2 of 2

Page No.0073
PERF
^4dberbcm Governm ent

Deputy Minister’s Performance Agreem ent
Personal Information . ;
Performance Cycle From Date (yyyy-mm-dd) Performance Cycle To Date fyyyy-mm-dd)
Last Name First Name
Department
Instructions:
• The completed Performance Agreement should be succinct (i.e. 3-4 pages) and should be used by Deputy Ministers to
highlight at a high level your main goals and results achieved.
• Comments should address both w h a tw \\\ be achieved and how it was achieved.
• This is a living document that may be updated to reflect issues and areas of focus that emerge throughout the year.
• Metrics/performance measures should be incorporated wherever possible to indicate progress on goals.
Performance
Ministry Focus: Department Priorities and Business Plan Goals
Com m itm ents th a t a re focused on business p lans o f the organization an d th a t reflect priority areas o f the G overnm ent.
Policy Support and Analysis
Ensuing the b est policy advice is provided to decision-m akers, inciuding advice and support to the M inister.
Goals/Actions T argets/Milestones Results
Program and Issues Management

Providing high-quality program s a n d services to Albertans.
Goals/Actions Targets/Milestones Results
Financial Management
Ensuring responsible stew ardship o f fiscal resources.
Leadership Results: Developing Leadership Capacity and APS Engagement

Com m itm ents th a t are focused on k e y organizational people priorities.
Succession and Talent Management
Supporting talent m anagem ent and succession fo r A D M s, executives a n d em ployees throughout the ministry.
Employee Engagement
Supporting departm ental and organizational engagem ent initiatives to build a positive workplace culture and influence the
ability to recruit, retain, an d engage em ployees.
WDE0002 (2015/09) Page 1 of 3

Page No.0074
PERF
Enterprise Focus: Supporting Organization-Wide Strategic Initiatives

Com m itm ents th a t a re focused on leveraging the broad strategic perspective o f the organization.
Cross-Ministry Initiatives
A ctively collaborating on a n d supporting cross-m inistry initiatives an d policies.
Alberta Public Service Organization Culture

Cham pioning corporate approaches to cultivate a o n e-em pioyer culture across the A lberta public sen/ice.
Learning and Development -

Identify key learning objectives to support personal development
(skills, com petencies, know ledge a n d experience required fo r current a n d future roles)
If unforeseen circumstances or issues arise that could affect my ability to deliver on these accountabilities, I will initiate the
process of redefining them with the Deputy Minister of Executive Council.
Date Deputy Minister
Date Deputy Minister of Executive Council
WDE0002 (2015/09) Page 2 of 3

Page No.0075
------------------------- PERF
Year in Review
Use the space below to succinctly summarize performance highlights over the past year.
Deputy Minister's Comments
{Highlight key results on your accountabilities, successes, key learnings, things you will focus on over the coming year (e.g. competencies, knowledge) and
any supports you'd like to receive.)
Deputy Minister o f Executive Council’s Comments

{Highlight key results, strengths demonstrated over the past year, areas of focus for coming year (e.g. competencies, knowledge, general contributions).)
Date Deputy Minister of Executive Council
WDE0002 (2015/09) Page 3 of 3

Page No.0076
PERF
Executive Manager on Executive Comm ittee

Government
___________________Performance Agreem ent
for the period
to
Date From_____________________________________ Date To
Executive Manager's Name My Employee ID#
Department Deputy Minister

For more Information on Performance Excellence click here.
My Commitments
To my Ministry: I will effectively manage the work of my ministry with a focus on achieving business plan goals, supporting the Deputy
Minister and managing issues, while fulfilling my budgetary responsibilities.
To my Corporation: I will actively support pod work (where applicable), collaboration across government and Reaching Our Full Potential
initiatives, including the Deputy Ministers' priorities of leadership, living our values and ending bullying.
To my Work Environment: I will demonstrate the APS values of Excellence, Respect, Integrity and Accountability in my decision making
and interactions with others and contribute to a positive work environment in my day-to-day wori<. I will implement succession strategies,
provide effective leadership and actively address employee engagement
To my Career and Learning: I will develop my skills and competencies for current and future roles, including teamwork, collaboration
and leadership and/or work actively to support knowledge and skills transfer to others.
To my Employees: I will have regular performance conversations with each of my employees, to provide the guidance and feedback they
need to be successful.
To my Deputy Minister: If unforeseen circumstances or issues arise that could affect my ability to deliver on these commitments, I will
initiate the process of redefining them with my Deputy Minister.
Other: Add any other specific commitments identified.
Deputy Minister's Commitment

I will provide context, guidance and coaching as needed to help you fulfill your commitments, including regular, focused performance
conversations throughout the year where I will enable honest, open balanced feedback.
Other: Add any other specific commitments identified.
Date Executive Manager

Note: Use My Performance Plan if you wish to record additional details regarding your commitments and outcomes achieved.
WDE0002 (2015/09) Page 1 of 2

Page No.0077
PERF
Government
My Performance Agreem ent
Part Two: My Year in Review
for the period
to
Date From Date To
Executive Manager's Name My Employee ID#
Department Deputy Minister

Our Conversations
Use the spaces below to note the dates of your performance conversations. Use M y Perform ance Plan if you wish to record the highlights
of your conversations.
Date: Date: Date: Date:
Performance Measures
Current Year’s Results
Commitments Measures Divisional
(Source: Corporate Employee Survey. See Appendix) (w here Ministry GOA
Corporate Focus: Collaborative Efforts available)
• Pod Work Percentage of employees who agree ministries and departments are
• Collaboration across government - --
working together to achieve the goals and priorities of the GoA
• Reaching Our Full Potential Percentage of employees who are somewhat or highly engaged (as
initiatives - —
a collective measure of "Reaching our Full Potential" initiatives)
Percentage of employees who feel that most senior managers in
their department or ministry act in accordance with the Alberta
Public Service Values
Percentage of employees who feel they are treated respectfully
at work
Working Environment Focus: Percentage of employees who agree they have opportunities for
-
People Focus career growth within the Government of Alberta
• Implementing succession strategies Leadership Index
• Producing effective leadership
• Actively addressing employee Employee Engagement Index
engagement and providing a quality
work environment Quality Work Environment Index
My Year in Review
Use the spaces below to summarize your performance highlights over the past year.
My Comments {Highlight key results on your commitments (such as achieving business plan goals, budget responsibilities, supporting the
Deputy Minister, collaboration, improving the work environment, etc), what you're most proud of, what you've learned from your
experiences, things you'd like to focus on over the coming year (e.g. competencies, knowledge) and any supports you'd like to receive.}
Deputy Minister’s Comments {Highlight your employee’s key results, the strengths he or she has demonstrated over the past year, and
things you’d like him or her to focus on over the coming year (e.g. competencies, knowledge, general contributions.}
Date Executive Manager
W DE0002 (2015/09) Page 2 of 2

Page No.0078
PERF
^ddberbtm Government My Performance Agreem ent

Part One: Our Commitments
for the period
to
Date From Date To
My Name My Employee ID#
My Department My Supervisor
My Com m itm ents
To my Job: I will contribute to my organization's success and fulfill my job expectations as identified in divisional and branch operational
plans (as applicable) and my job responsibilities.
To my Branch, Division, Department: I will actively support my team and collaborate with others to achieve branch, divisional,
department or GOA goals.
To my Work Environment: I will demonstrate the APS values of Excellence, Respect, Integrity and Accountability in my interactions with
others and contribute to a positive work environment in my day-to-day work.
To my Career and Learning; I will develop my skills and competencies for current and future roles, including teamwork, collaboration
and leadership and/or work actively to support knowledge and skills transfer to others.
To my Employees (for those who supervise others) I will have regular performance conversations with each of my employees, to
provide the guidance and feedback they need to be successful.
To my Supervisor: If unforeseen circumstances or issues arise that could affect my ability to deliver on these commitments, I will initiate
the process of redefining them with my supervisor.
Other: Add any additional commitments identified by you and your supervisor.
My Supervisor's Com m itm ents

I will provide context, guidance and coaching as needed to help my employee fulfill his or her commitments, including regular, focused
performance conversations throughout the year.
I will live the APS values every day and will enable honest, open and balanced feedback to help my employee grow and develop.
Other: Add any additional commitments.
Date Employee
Date Supervisor
Note: Bring My Performance Agreement to each performance conversation with your supervisor, and note the dates of each conversation
under Part Two - Our Conversations. Use My Performance Plan to help you and your supervisor track your commitments, contributions
and conversations. My Performance Plan is for your use only and will not be placed on your employee file unless specifically requested
by you and/or your supervisor.
WDE0002 (2015/09) Page 1 of 2

Page No.0079
PERF
Government
My Performance Agreem ent
Part Two: My Year in Review
for the period
to
Date From Date To
My Name My Employee ID#
My Department My Supervisor
O u r Conversations
Use the spaces below to note the dates of your performance conversations. Use My Performance Plan if you wish to record the highlights
of your conversations. If conversations occur on a regular basis, please feel free to note the frequency in the year in review
comments below.
Date: Date: Date: Date:
My Y ear in Review
Use the spaces below to summarize your performance highlights over the past year.
My Comments {Highlight key results on your commitments, what you're most proud of, what you’ve learned from your experiences over
the past year, any performance improvements made, and things you’d like to focus on over the coming year (e.g. competencies,
knowledge, general contributions) and any supports you’d like to receive.}
My Supervisor's Comments {Highlight your employee's key results, competencies and strengths he or she has demonstrated over the
past year, and things you’d like him or her to focus on over the coming year (e.g. competencies, knowledge, general contributions.)}
□ Check here if performance issues or concerns have been addressed at any time in the year and complete the section that will appear below.
Date Employee
Date Supervisor
Date Manager (at least one level above supervisor)
Note: Once your completed P e rfo rm a n c e A g re e m e n t has been signed by a Manager at least one level above your
supervisor, you will receive one copy and another will be placed on your employee file.
W DE0002 (2015/09) Page 2 of 2

Page No.0080
Municipal Affairs
Vacation Request
This Form is for Branch Use Only
Do Not Forward to Human Resource Services
To be used for pre-authorized absences

Em ployee's Name Date of Request
I I Annual Vacation Q Management Supplement Q Other
V acation Hours Year Hours Year

Carried Forward
Management Supplement
Carried Forward
From To Number of Hours

(m ortth/dayfyear) (m onth/day/year) Hours (S tate actu al hours ie. 8 :1 5 to 12:00)
R em arks:
Signature of Employee Approval of Supervisor Approval of Director or Designate

Page No.0081
Municipal Affairs
Temporary Staff Request
Date
Classification Start Date End Date Reporting To Telephone Number
Branch Location
Description of Duties:
Special Equipment
I I Dictaphone Q Calculator Q Word Processing Q Data Processing
I I Other (specify):
Comments or Special Requirements:
Signature of Expenditure Officer Date
FOR HUMAN RESOURCE SERVICES USE ONLY

Date Request Placed Name of Temporary Agency Contacted Telephone Number
Name of Recruitment Officer Name of Candidate Selected
Rate of Pay Start Date Termination Date
Comments
MA0680 (1999/07)
Page No.0082
Government
of Alberta ■
Time Approver/Reviewer Request Security Form
• This form is required for the set up and updating of new and existing
ministry Time Approvers/Reviewers and associated Department ID’s.
• Note that authorization by the worksite Expenditure Officer is required.
• Submit the approved form to your ministry Time Approver Coordinator.
• Please note that it takes 24 hrs. to take effect
□ Approver □ Reviewer
Employee ID: ______________________

Name: ______________________
Effective Date: ______________________
End Date (acting purposes): _____________________
Action:
[ ] Add New or Change Time Approver/Reviewer Role
Please complete the table below.
Add Department ID Remove Department ID
[ ] Remove Existing Time Approver Role
Ministry Nam e:____________________
Business U nit:____________________
Expenditure Officer Nam e:_________
Expenditure Officer Signature______
D ate:_____________________________

Page No.0083
CANADA
P R O V IN C E O F A L B E R T A
}
OFFICIAL OATH
I , _________________________________________________________
do swear that I will execute according to law and to the best of my ability
the duties required of me as an employee in the public service of Alberta
and that I will not, without due authorization, disclose or make known
any matter or thing which comes to my knowledge by reason of my
employment in the public service.
SO HELP ME GOD
(omit i f affirmed)
(Signature of Employee)
TAKEN and subscribed before me
at_________________________________________________
this___________________________________________day of
________________________________________ , A.D. 20___
C lerk o f E x ecu tiv e C ou n cil, or J.P., N .P .,

C o m m issio n er for O aths
T O BE R ETA INED ON T H E EM PLO YEE PERSO NAL FILE

Page No.0084
2015/ *
2016
Grant Application Septem ber 30, 2015
Deadline
Refer to the Ground Search and Rescue Program Guidelines at

www.ofc.alberta.ca for information on eligibility.
Ground Search and Rescue - Program Application
Applicant Inform ation
Name of group/organization
Legal status of applicant

(if applicable)
Contact name and title
Contact primary phone number
Contact email address
Contact mailing address
Contact fax number
|p r o je c t Inform ation/Training Plan
(
Project completion date
(Month/DD/YYYY)
May 31, 2017
1
£
Page No.0085
Ground Search and Rescue and technical rescue courses available in
2012/201 3
Refer to Guidelines for description and number the course (s) in order of preference
(1 - most preferred; 6 - least preferred)
Check
Course/activity
0
2-day Team Leader Course
2-day SAR Search Manager

Recertification Course
Tabletop Exercise
Provincial Exercise
5-day Search Manager

course
Train the Trainer
ATU or UTV Safety Course
Boating Course
Snowmobile Course
Man-tracking
GPS Tracking
SAR Searcher Course
Wilderness First Aid
Swift Water Rescue
Rope Rescue
Standard First Aid
Specialized Technical

Page No.0086
2015/
2016
Project Results/Proposed Training Plan
Output Total expected number of

attendees
Trained SAR Personnel
Training Plan - Please fill in one table for each of the courses/activities you wish to host
Name of Trainer or Business to be Contracted
Cost of trainer/training $
$
Facility
$
Meals and snacks {if provided)
Participant lodging $
Participant mileage $
$
Training materials
Other costs not outlined above
$
Total grant amount you requested
3
Page No.0087
Total estimated cost of training
Partnership Inform ation
Will you be partnering with

other SAR Alberta member □ Yes □ No
teams
If yes, attach letters of support from supporting groups.
Supporting Docum entation and Application Submission
Application Form Checklist

|
Did you include: Check 0
Estimated training cost for each course you wish to host?
□
(See Guidelines, Appendix 2)
Proof that your group is registered under the Alberta Societies Act?
D I
1 Submit the grant application and supporting documents via
mail/fax/email.
Grants Coordinator
Public Safety Division
Submission address
16th floor, Commerce Place
1 0 1 5 5-10 2 Street
Edmonton, Alberta T5J4L4
Fax: 780-427-2538
Email: firecomm(5)gov.ab.ca
Reminder:
This application is due Septem ber 30, 2015
F
Page No.0088
2015/
2016
■A pplication Certification
I certify that the information contained in this application form is correct, that all Ground Search and
Rescue funds will be used in accordance with the Ground Search and Rescue Program Guidelines and that
the allocated grant amount will be applied in the year(s) and manner described above once this application
form has been accepted by the Minister,
Signature Date Signature Date
Search and Rescue Group President Search and Rescue Group Treasurer
Signature Date
Office o f the Fire Commissioner

Fire Rescue Officer
% of Total Project
Functional category of the project (Office use only)
Costs
G overnm ent-wide objective 4: To support capacity building within
municipalities
Volunteer Development 100%
TOTAL 100%
Group Direct Deposit Inform ation
5
Page No.0089
Financial in s titu tio n name
Address
City
Province
i rie personal mrormdLion ueing conecieu on uiib lurm win ue ubeu lu dum m isiei me vjiuumu
Search and Rescue Program. The information is being collected under the authority o f section
33(c) o f the Freedom o f Information and Protection o f Privacy (FOIP) Act and will be managed in
accordance with the privacy provisions in the FOIP Act. If you have any questions concerning the
collection o f this information, please contact:
Grants Coordinator
10155 -1 0 2 Street
Edmonton, Alberta T5J 4L4

Page No.0090
y^dlaerbc^j
Fire Services and Emergency

Preparedness Program (FSEPP)
2015/16
ADDlication Form
WWW
This program supports expanding and enhancing regional fire and

emergency management training.

Page No.0091
2015/
2016
1. Objective of the FSEPP In 2015/16:
Fire Services and Emergency Preparedness - Program Application
The objective of the Fire Services and Emergency Preparedness • Apply for either emergency
Program is to provide an effective and cost-efficient mechanism for management training or fire
increased training capacity that results in an increased number of services training using this
trained fire service and emergency management practitioners. application form.
FSEPP is open to ail
1.1 Application
September 30, 2015 municipalities and First
Deadline
Nations regardless of
See section 3 of FSEPP Guidelines at population size.
1.2 Eligibility
www.ofc.aiberta.ca/grant-funded-
Criteria
training.cfm and www.aema.alberta.ca
2. Applicant Information
2.1 Name of
municipaiity/organization or First
Nation (If organization please list
municipality administering the
grant)
2.2 Legal status of entity

(if applicable)
2.3 Contact name and title
2.4 Contact phone number
2.5 Contact email address
2.6 Contact mailing address
2.7 Contact fax number

Page No.0092
3. Project Information
( ^ E ir e Services Training
3.1 Under which of these
does your project fail? Check (^^ m e rg e n c y Management Training
ONE.
3.2 Is this an amendment? N/A
3.3 Name of project Training
Course (Choose from list on page 7 of Guidelines)
3.4 Description of project/

courses you plan to
administer
Other
(Specify course)
Fill out the Estimated Cost of Training table on page 10 of this

form for each course you have entered above. Include all
sheets with this application.
If you filled in "Other", go to section 6.2 of this form.

Page No.0093
2015/
2016
3.5 Project completion date May 31, 2017
3.6 If you are not

collaborating with other
municipalities/organizations
to administer the project,
are there other municipal
beneficiaries of the program
funds? If so, please list.

Page No.0094
3.7 Project/training costs See example on page 4 of FSEPP Guidelines.
{A} {B> {C> {D} {E}
Project Phase Non-provincial sources of

Estimated eligible Other provincial grants expected
Milestone/Course funding ($)
Funding request
Grant Name Amount ($) Source Amount ($) under this grant
program
|A-(C+D)]
Total N' A $ 0 .0 0 N' A $ 0 .0 0 $ 0 .0 0

$ 0 .0 0
TT

Page No.0095
Identify the functional categories of the project.
3.8 Functional category of the project % of Total Project Costs
Government-wide Objective 4: Programs supporting capacity building within municipalities.
Staff Development 100%
TOTAL 100%
4. Functional Category Details 1

Identify expected outputs.
Output Expected Quantity Unit
Category Quantity
Staff Development
Trained personnel N/A Number of personnel

trained
5. Collaboration
5.1 Will you be collaborating with Q.

another municipality/organization?
o
5.2 If yes, provide the names of the
municipalities/organizations with
whom you are collaborating.
5.3 Briefly describe the nature of the

collaboration (maximum 100 words).
* A letter of support is required from
each partner.
5.4 If there is a resulting asset,

please indicate who will own the
asset.

Page No.0096
6. Supporting Documentation and Application Submission
6.1 Explain how the training you intend to administer will benefit your community.
6.2 Provide full description of any additional courses (See Guidelines Appendix 1, Note 6).
6.3 Method of Submission M ail, fax, or email th e application.
Grants C oordinator
A lberta M unicipal Affairs
6.4 Submission address 16th flo o r, 10155 - 102 Street
Edm onton, A lberta T5J4L4
Fax: 780-427-2538
Email: firecom m @ gov.ab.ca
Reminder: This application is due September 30, 2015.
Te
Page No.0097
I certify that the information contained in this application form is correct, that all Fire Services
Emergency Preparedness Program (FSEPP) funds will be used in accordance with the FSEPP
Guidelines and that the allocated grant amount will be applied in the year(s) and manner
described above once this application form has been accepted by the Minister.
Print Name(Regional Training C o-ordinator)*
Signature Date
*Note: (see Section 2 Applicant Information)
Print N am e(M unicipal/First Nation A d m in istra to r)*
Signature Date
Reviewed by:
Signature Date Signature Date
Office o f the Fire Commissioner Alberta Emergency M anagem ent Agency

Fire Rescue O fficer Field O fficer
Note: If applying for fire services training grant, only fire field officer signature is required, if
emergency management grant then only AEMA officer signature. See page 6 of FSEPP
Guidelines for a list of officers.

Page No.0098
8. Useful Resources
Office of program contact Contact phone number Contact email address
Grants C oordinator 1-866-421-6929 firecom m @ gov.ab.ca
Website address
Office o f the Fire

w w w .ofc.alberta.ca
Com m issioner
Alberta Emergency
w w w .aem a.aiberta.ca
M anagem ent Agency
9. Legal Statements
The personal info rm a tio n being collected on this fo rm w ill be used to adm inister the Fire Services
Emergency Preparedness Program. Any persona! in fo rm a tio n is being collected under the
a u th o rity o f Section 33(c) o f the F re e d o m o f In fo r m a tio n a n d P ro te c tio n o f P riv a c y (FO IP ) A c t w ill
be managed in accordance w ith th e privacy provisions in th e FOIP A c t. If you have any questions
concerning the collection o f this inform a tion , please contact:
Grants C oordinator
Alberta M unicipal Affairs
16th flo or, Commerce Place
10155 - 102 Street
Edm onton, Alberta T5J4L4.

Page No.0099
2014/
10. Vendor Profile (Fill out only if vendor not on file with Municipal Affairs)
Required information
N am e o f m u n ic ip a lity /o rg a n iz a tio n
F inancial in s titu tio n n am e
A d d re ss
C ity
P ro vin ce
P ostal co de
T ra n s it n u m b e r
A c c o u n t title
T ype o f a c c o u n t

Page No.00100
11. Estimated Cost of Training Fill out one copy for each course.
Name of Course
Name of Trainer or Business to be contracted (if applicable)
Cost of Trainer/Training $
Facility rental $
Meals and snacks (if provided) $
$
Participant lodging
$
Participant mileage
Training materials $
Other costs not included above (specify)
Total Amount Requested $0 .0 0
Is your Application Complete?
* Have you filled out all applicable sections?
• Have you included Estimated Cost of Training sheets for all the courses
you are requesting?
10

Page No.00101
Government
Fire Services and Emergency

Preparedness Program
Reporting Documents
www.ofc.alberta.ca
This program supports expanding and enhancing regional fire services

training and emergency management training in preparation,
response and recovery enabling effective municipal emergency
management systems.
Government

Page No.00102
jTfi
Municipal Affairs
Fire Services and Emergency Preparedness Program
Due: June 30, 2017
Reporting Form Instructions
How do I complete program reporting?

There are various tabs contained in this Reporting document which need to be completed. The tabs are described in more
detail below.
Tab Name Description
Completion Summary This tab provides a summary of all the requirements in the reporting form. When all of the
required fields in the reporting tabs are complete, the red "Incomplete" cells will turn to a
green "Complete." The Completion Summary provides a checkpoint for grant recipients to
ensure that all of the required fields in the tabs are complete.
Basic Information This tab contains basic information such as key contact information for the grant recipient
submitting the report as well as program contact information if there are any questions
on completing the requirements.
Financial Reporting The financial reporting tab is a statement of funding and expenditures. Specific
instructions for completing the various fields in this report are noted as comments in the
specific cells.
Reporting on Results The information collected in this tab is used to assess the progress of the project in
meeting its expected outputs (as originally identified in the application form). Any
variance from the expected results to the actual results achieved should be explained.
Supporting Documents Supporting documents could include evidence that funding was spent in accordance with
the conditions of the grant agreement or any additional requirements that are specifically
relevant to the nature of the program or type of projects and activities funded.
Program Evaluation This section is optional to complete. The purpose of the program evaluation is to provide
an opportunity for the grant recipient to share thoughts and suggestions on the grant
program. This information will be used by the program to evaluate results and determine
How do I submit reporting?

Method of Submission Submit the signed grant reporting package via mail, fax, or email to:
Grants Coordinator
16th Floor Commerce Place
10155-102 Street
Fax: 780-427-2538
firecomm(2>qov.ab.ca

Page No.00103
Municipal Affairs
Due: June 30, 2017
Com pletion Sum m ary
^ _____________
Basic Information Incomplete
Financial Reporting Incomplete
Reporting on Results Incomplete
Supporting Documents Incomplete
Program Evaluation O p tio n a l

Page No.00104
Municipal Affairs
Due: June 30, 2017
Basic Inform ation
1. M unicipality / Organization inform ation
Information of primary contact at municipality or organization
Legal name o f entity
Legal status o f entity
2. Program assistance
Please contact the Grants Coordinator for assistance on completing the reporting requirements
Contact email address (if

Office o f program contact Contact phone number
applicable)
Grants Coordinator 1-866-421-6929 firecomm(5>ciov.ab.ca

Page No.00105
Municipal Affairs
Due: June 30, 2017
Statem ent of Funding and Expenditures
M u n icip a lity o r R e gio n a l T ra in in g H ost
PROJECT EXPENDITURE LIST

N am e o f E m e rge n cy M a n a g e m e n t
C ourse T o ta l A m o u n t N am e o f Fire Services T ra in in g Course T o ta l A m o u n t
Total Grant Am ount

Note: All projects listed on this statem ent must first be accepted on a previously submitted grant application for this reporting
year.
O th e r (p le a se p ro v id e d e ta ils b e lo w ):________________________________________________________________________________________________________
CERTIFICATION
I certify that th e follow ing inform ation is tru e and correct:
* All inform ation contained in this Statem ent of Funding and Expenditures is a true and correct represenation o f actual funding and expenditures and this inform ation com plies w ith
the Guidelines, Adm inistrative Procedures, and o ther relevant d ocum entation for this grant program .
- Al? non-shareable co sts defined for th is program have been ded ucted from the total co st o r o therw ise excluded from the am ounts identified as Net Eligible Project Cost.
- T h e entire g rant (plus any incom e earned, if applicable) w as used for the purpose(s) stated in the Conditional Grant A greem ent, w ithout m aterial alteration, as signed by the M inister
o f M unicipal Affairs o r his delegate.
- The grant (plus a ny incom e earned, if applicable) w as expended and the w ork w as com pleted by by the date stated in the Conditional G rant Agreem ent.
- T h e m unicipality/organitation did not use any portion o f the gra n t to pay for w ork d one o r m aterials obtained prior to the signing date o f the Conditional G rant Agreem ent.
In all respects, th e Inform ation in this Statem ent com plies with the term s o f the current Program Agreem ent between M unicipal Affairs and the M unicipality.
Signature
Ch ief Adm instrative O ffifcer
Signature
D irector o f Em ergency M anagem ent or

Regional Train ing Host o r Delegate

Page No.00106
Municipal Affairs
Due: June 30, 2017
R eporting on Results
Functional Category o f Project
Identify the functional category(ies) under which the project applies and indicate what percentage of total actual
project costs were spent per category. If there were no expenditures made under the functional category, insert
"0%" in the "% of Total Actual Project Costs column."
% of Total Actual Project

Functional Category of the Project Costs
Government-wide Objective 2: To
support capacity building within
municipalities
- Staff Development 100.00%
Total 100.00%
Project Results
Identify the outputs that were achieved by the project. Referring to program guidelines
for additional inform ation on how to complete this section. If there were no outputs for a
specific category, insert "0" in the respective cell in the "Actual Quantity" column,
otherwise the Completion Summary tab will indicate "Incomplete."___________________
Output Actual Quantity Unit
Trained personnel Number of personnel
trained
If there were variances from the expected results to the actual results achieved, please
explain.

Page No.00107
Municipal Affairs
Due: June 30, 2017
Su pp orting D ocum ents
1 Provide the documents listed in the table below.

2 Submit supporting documentation by mail, fax, or email.
3 If you have any questions on the completion o f this section, please please refer to the "Basic
Inform ation" tab for program contact information
Supporting Documents Checklist
Check "Yes" or "No" fo r each supporting document required, as applicable. If Yes or No is not checked
off for each supporting document, it will not show as "Complete" in the Completion Summary Tab.
Required documentation Submitted (Yes/No)
Yes □
Reporting Documents
1 No □
Yes □
Course List
2 No □
Yes □
Class List
3 No □
Yes □
Trainer's Report
4 No □
Yes □
Receipts
5 No □

Page No.00108
Municipal Affairs
Due: June 30, 2017
Program Evaluation
Grant Program Structure
Please provide comments and ideas for the future with regards to how the grant program helps
your municipality / organization meet its needs.
Grant Program Administration
Please provide comments and ideas for the future with regards to the administration of the grant
program.
Other Comments
Please provide other comments you have regarding the grant program

Page No.00109
Training must be completed
Training Deadline
by May 31, 2017
Reporting document is due on

Reporting Deadline
or before June 30, 2017
Reporting Refer to the Ground Search and Rescue Program Guidelines at

Requirements w w w .ofc.alberta.ca fo r info rm a tio n on reporting requirem ents.
Ground Search and Rescue - Reporting Form
Grant Recipient Information
Name of group/organization
Legal status of applicant

(if applicable)
Contact fax number
Program Assistance
If you need any assistance com pleting this reporting fo rm , please contact:
Grants C oordinator
1-866-421-6929
firecomm(5)gov.ab.ca

Page No.00110
Statement of Funding and Expenditures
In th e Description o f Expenses table, e nte r the name of each course yo u r group/organization
hosted, using one row per course. In th e Total A m ount per course colum n, e n te r th e sum o f all
expenses fo r the course. Ail courses listed m ust have been identified in th e Project Plan section o f
yo u r original grant application. Calculate your Surplus/O verrun in th e Use o f Funds table.
Description of Expenses
Total Amount Per

Course Name
Course
$
•uv
Total Expenses
o
o
o
Use of Funds
Total Grant Amount $
Total Expenses (from table above) $ 0 .0 0

■VT-
o
o
o
Surplus/Overrun (Total Grant A m o u n t-T o ta l Expenses)
Alberta Municipal Affairs Information Reque st 2015-R-0088

Page No.00111
Certification of Statement of Funding and Expenditures
I ce rtify th a t th e fo llo w in g info rm a tio n is tru e and correct:
All in fo rm a tio n contained in this S tatem ent o f Funding and Expenditures is a tru e and correct
representation o f actual funding and expenditures, and this info rm a tio n complies w ith the
Guidelines, A d m inistrative Procedures, and o th e r relevant docum entation fo r this grant
program .
Ail non-shareable costs defined fo r this program have been deducted fro m th e to ta l cost or
o therw ise excluded from th e am ounts identified as Net Eligible Project Cost.
The e ntire grant (plus any income earned, if applicable) was used fo r the purpose(s) stated in
the C onditional G rant Agreem ent, w ith o u t m aterial a lteration, as signed by th e M in iste r o f
M unicipal Affairs o r his delegate.
The grant (plus any income earned, if applicable) was expended and the w o rk was com pleted
by th e date stated in the C onditional G rant Agreem ent.
The m un icipality/organization did not use any p ortion o f the grant to pay fo r w o rk done or
m aterials obtained p rior to th e signing date o f the C onditional G rant Agreem ent.
Signature Date
Printed Name
S e a rc h a n d R e scu e G ro u p P re s id e n t
Signature Date
Printed Name
S e a rc h a n d R e scue G ro u p T re a s u re r

Page No.00112
Results Reporting
In th e Total Actual N um ber o f Attendees column o f the table below, e n te rth e to ta l num ber o f
individuals w ho attended all o f th e courses yo u r group/organization hosted. Report the actual
attendance, not th e estim ated attendance provided in yo u r Project Plan.
Output Total Actual Number of Attendees
Trained SAR Personnel
If th e actual project results d iffe r fro m the expectations provided in yo u r Project Plan,
please provide com m ents / explanations below.
FOR OFFICE USE ONLY

% of Total Project
Functional Category of the Project
Costs
G o v e rn m e n t-w id e objective 4: To support capacity building w ith in

m unicipalities
V o lun te er Developm ent
TOTAL 100%
Alberta Municipal Affairs Information Reque st 2015-R-0088

Page No.00113
2015/
2016
Supporting Documentation and Application Submission
Reporting Form Checklist

Did you include: Check 0
□□
Course(s} Offered as listed in C onditional G rant Agreem ent
Course Expense Sheet and Receipts

Subm it the R eporting Form and supporting docum ents via

Method of Submission
m a il/fa x/em a il.
Grants C oordinator
Submission address
16th flo o r. Commerce Place
10155 - 1 0 2 Street
Edm onton, Alberta T5J 4L4
Fax: 780-427-2538
Email: firecomm(5>gov.ab.ca
Reminder:
This report is due June 30,
2017

Page No.00114
Program Evaluation
Please provide feedback on how the grant program helps yo u r m unicipality /

organization m eet its needs. W h a t changes / im provem ents can w e make?
Grant Program Administration
Please provide feedback on how the grant program is adm inistered. W hat changes /
im provem ents can w e make?
Other Comments

Page No.00115
2015/
2016
Legal Statements
The personal info rm a tio n being collected on this fo rm w ill be used to adm inister th e Ground
Search and Rescue Program. The inform a tion is being collected under the a u th o rity o f section
33(c) o f th e F re e d o m o f In fo r m a tio n a n d P ro te c tio n o f P riv a c y (FOIP) A c t and w ill be managed in
accordance w ith th e privacy provisions in th e FOIP Act. If you have any questions concerning the
collection o f this inform a tion , please contact:
Grants C oordinator

16th flo o r, Commerce Place
10155 - 102 Street
Edm onton, Alberta T5J 4L4

Page No.00116
COURSE CHANGES/EXTENSION REQUESTS
M unicipality___________________
Grant Year: ___________

Course Change:
Would you like to change/add a course?
O
O
Is the course on the approved list of courses?
O ______________
On°
If not, what is the course being requested and reasons for requesting?
* Extension Requests:
Do you require an extension?
(reporting documents for completed courses must still be submitted to the Minister by June 30, 2014)
O
Time frame you would like to extend? (Maximum 6 months)*
Reason why?
*AII grant extensions will require an amendment to the CGA
Please submit all forms to:
Grants Coordinator at firecomm@gov.ab.ca or fax 780-427-2538

Page No.00117
CRITICAL INCIDENT REPORTING
P u rp o s e : P r o v id e s u c c in c t in fo rm a tio n to th e E x e c A s s is t a n t to th e A D M , o n is s u e s (e x is tin g o r a ris in g )

c o n c e r n in g P S D . T h is in fo rm a tio n m a y b e fo r w a r d e d to th e A D M .
T h e in te n t is n o t to re p la c e A c tio n R e q u e s ts (A R ) a n d to b e p r o a c tiv e b y r e p o r tin g is s u e s in its

e a r ly s ta g e s .
D a te o f In c id e n t
S u b je c t
-subject matter / existing issues /arising issue
•
P a rtie s In v o lv e d
[government staff, stakeholders, agency, etc.]
In c id e n t D e ta ils (4 -5 bullets)
•
•
•
•
A c tio n
-What is or what will be done about the nature of the incident?
-What is expected to be done and when?
•
O u tc o m e
-Based on the action, what are the possible outcomes?
•
M e d ia S e n s itiv itie s
•

Page No.00118
j^ C m b O v *
DISPLAY UNIT BORROWING GUIDE & AGREEMENT
UNIT REQUIRED __ Fire Safety: It’s Easy as 1-2-3
__Learn Not To Burn
LOAN POLICY Fax the completed form to 780-415-8663. Allow 1-3 days for shipping).
The display unit must be returned on or before the return date.
SHIPPING Fire departments/borrowing organizations must make ALL

arrangements for shipping and pay shipping charges (pick up and
delivery from/to the Office of the Fire Commissioner by a courier
service of their choice.). Shipping date will be confirmed by phone/
e-mail when the OFC gets the completed form.
Pick-up/retum address:
16lh floor, Commerce Place
10155-102 St.
Edmonton T5J 4L4
LOSS OR DAMAGE When you get the unit, check for missing/damaged items. If a display item
is missing or damaged please contact our office immediately at
1 866 421 6929.
If an item is lost or damaged the fire department/borrowing

organization will be charged for the replacement cost. (Approximate
cost of unit is $1,800)
Display unit is required from: shipping date:__/ __ / 20__ to return date:__ /__ / 2 0 _
Fire chief s/borrowefs name (Print):_________________________

Fire department/organization name: _______________________________
Shipping a d d r e s s : ___________________________________________
Phone: ____________________Fax
Email: _______________________
Signature (fire chief/borrower): _________________
I hereby agree to the above conditions
Office of the Fire Commissioner

www.ofc.alberta.ca page 1 of 1

Page No.00119
SPARKY COSTUME BORROWING GUIDE & AGREEMENT
BOOKING STEPS
Complete this agreement and fax it to 780-415-8663.
1. You will receive a confirmation/availability email.
2. After your booking is confirmed, you must arrange for a courier company {at your cost) to pick up
costume from the OFC at the address beiow.
3. Call 1 866 421 6929 or email firecomm(5)gov.ab.ca with your name, and date and time of pickup, and the
name of the courier company.
4. Courier pickup and delivery is Monday to Friday 8:15 to 12 and 1 to 4:30 pm.
Borrowers pay ALL shipping charges (pickup and delivery) from and to Office of the Fire Commissioner.
LOAN POLICY
> Costumes w ill not be released u ntil w e have a signed copy o f this agreement.
> Costume m ust be returned on the date you state below.
> Before returning the costumes, air o ut th e garm ent. Please check th a t all the com ponents are accounted fo r.
> If you receive a damaged or incom plete costum e, please rep ort th e fact im m ediately at 1 866 421 6929.
> Pick up and retu rn costume, at your cost, to the fo llo w in g address:
Office o f the Fire Com m issioner

16th flo o r, Commerce Place
10155-102 Street
Edm onton, AB T5J 4L4
LIABILITY
> Borrowers are responsible fo r any loss, delay o r damage to the m aterials. Sparky's helm et is especially delicate and w ill
be damaged if dropped on a hard surface!
> If an item is lost or damaged, th e borrower w ill be charged the replacement cost.
I hereby agree to the above c o n d itio n s:Q ] Signature
B orrow er Name (Please print) Title

Email Address Phone
Shipping Address
Shipping date fro m OFC Return date

Name o f Courier Company
OFC Use Only

Page No.00120
yidhzrbtKM
S P A R K Y T H E FIR E DOG
C H E C K L IS T
Replacement Check before leaving (lie OFC Check by borrower upon Check by borrower before
Description of items Cost receiving the costume returning the costume
HEAD WITH HELMET SI 250.00
2 BOOTS S300.00
COAT S300.00
PANTS S300.00
2 GLOVES $200.00
8AA BATTERY PACK $235.00
(BATTERIES NOT
INCLUDED)
SHIPPING CASE $1250.00
Person checking - Name
Signature
Date

Page No.00121
SPARKY MASCOT PROTOCOL AND ETIQUETTE
TALKING
Never talk while in the presence o f people. Remember that you are an animated character and animated characters
do not talk.
EXPOSURE
N ever take any part o f the costume o ff while in public view . D o not reveal your true identity. I f you must take o ff
any part o f the costume, do so in seclusion.
DRUGS AND DRINKING

D o not drink or take any drugs before performing in the costume. Y o u ’ ll need complete concentration as a
performer.
CHARACTER ROLE
A lw a ys play the role. N ever get out o f character while in costume. Remember what people are seeing ... a cuddly,
costumed character, not John or Jane Doe.
FAIRNESS
D o not play favourites. D o not approach males more than females (or vice versa), children more than adults (o r vice
versa).
REMEMBER
D o not be embarrassed. People only see the costumed character and not the person inside. Be imaginative,
outgoing and energetic!

Page No.00122
Government LEAD IN S TR U C TO R A G R E EM EN T
LEAD INSTRUCTOR INFORMATION P le a s e p rin t c le a rly a n d D O N O T u s e initials.
Surname First Name Department for whom you are training
Address Email Phone
NFPA Standard Level Dates of training (from/to) (mm/dd/yyyy)
INSTRUCTOR TRAINING PROCEDURES
The following training procedures must be READ immediately upon receiving your instructor package. You must FOLLOW ail of the
procedures listed here before, during and after the training. After the training, SIGN the declaration confirming that you have read and
followed all of these procedures and give it to the proctor for submission to the OFC.
B E F O R E T H E T R A IN IN G
• Submit proof of the following qualifications to the OFC:

o NFPA 1041 Fire Service Instructor Level I (or 1041 Level II for instruction of 1041 courses)
o Successful completion or certification of the course to be instructed
• Check that the instructor package contains the following items:
o instructor Agreement (this document)
o Complete list of skills
o Skills sheets
o Course registration sheet (sign-in sheet)
• If any of these items are missing, contact the OFC immediately.
• Prepare and collect the resources required for the training (e.g., lesson plans, textbooks, PowerPoints, student handouts).
• Plan to teach all of the Job Performance Requirements (JPRs) for the level. Refer to the NFPA Standard and Level listed on the NFPA
website.
N O TE: An instructor conducting training fo r the first time can expect to spend approxim ately two hours in preparation fo r every
h o u r o f presentation. A preparation-to-presentation time ratio o f 2:1 fo r the training being taught is recom m ended. For
example, five days o f training will require ten days o f preparation time. A s you becom e fam iliar with the materials, this
preparation time can be reduced.
• Ensure you have the tools, equipment, PPE and facilities required to complete the training.
• Check the facilities where the training will be occur to ensure they are a safe and healthy environment (e.g., temperature, air
quality, lighting, space). Refer to NFPA 1403 Live Fire Training Evolutions, O ccupational H ealth and S afety Act, R egulation and
Code, and any local regulations, resolutions, municipal bylaws, and provincial and/or federal legislation.
• Check with the host department to determine if there are any candidates with disabilities and plan for any special
accommodations that will be required. The OFC must be notified on what accommodations will be required.
D U R IN G T H E T R A IN IN G
• Have every candidate sign the course registration sheet before training starts. Confirm the number of candidates with the host
department. If the number of actual candidates differs from the number of candidates listed on the original host application, contact
the OFC immediately with the new number of candidates.
• Treat all candidates fairly and with respect. Discrimination against any candidate will not be tolerated. The Office of the Fire
Commissioner expects instructors to treat all candidates in accordance with the Canadian C harter o f R ights and F reedom s and
the A lberta Human R ights Act.
• Remain objective when dealing with the candidates and considerate of their individual circumstances. Do not treat any candidate
preferentially or place any individual or group at a disadvantage compared to any other individual or group. Treat ail candidates
as equally valued participants.
O ffice o f th e Fire C o m m issio n e r

w w w .o fc .a lb e rta .c a
J u ly 2 0 1 5
Alberta Municipal Affairs Information Request 20)5-R-0088
Page No.00123
• Allocate sufficient time for candidates to practice performing all practical skills. Indicate with a check mark under each candidate’s
name on the Instructor Practical Skills Checklist if the candidate has completed each skill successfully.
• Prior to the scheduled testing date(s), forward a copy of the Course Registration sheet to the proctor and the evaluator. Retain a copy
for your records.
A F T E R T H E T R A IN IN G
• Do NOT act as the evaluator for the course. An instructor cannot be qualified as the evaluator for a course he/she has taught.
• Upon completion of training, make sure all paperwork has been filled out and signed. Deliver the Instructor practical skills checklist
and the original signed Instructor Agreement to the proctor. Retain a copy for your records. Also pass along any video presentations,
reports and candidate assignments, if applicable (e.g., 1021,1041).
DECLARATION
I , ______________________ ________________________________ , have complied with all of the training requirements and procedures
listed here as specified by the Office of the Fire Commissioner and confirm that I have read these procedures before the start of the training. I
understand that failure to follow these procedures may result in suspension of my duties as an instructor, proctor, and evaluator for certification
processes with the Office of the Fire Commissioner.
SIGNATURE_______________ DATE
QUESTIONS?
Email: ofc.certificationexam@gov.ab.ca
Website: www.ofc.alberta.ca
'Th is collection of personal information is necessary to support the certification and accreditation programs of the Office of the Fire Com m issioner. The collection is authorized under
Section 33© of the Freedom o f Information and Protection o f Privacy (FOIP) A ct and will be managed in accordance with the privacy provisions in the Act. If you have questions
regarding the collection of your personal information, please send your inquiry to the Office of the Fire Com m issioner, te 1" Floor, Commerce Place, 10155 - 102nd Street. Edmonton, AB,
T 5 J ALA or email ofc.certificationexam@ gov.ab.ca.
Office of the Fire Com m issioner

www.ofc.alberta.ca
Ju ly 2015 Alberta Municipal Affairs Information Request ,2015-R-0088
Page No.00124
E X A M /E V A LU A T IO N IR R E G U LA R ITY
PROCTOR / EVALUATOR INFORMATION
Surname First Name Middle Name
NFPA Standard and Level Date (mm/dd/yyyy)
CANDIDATE INFORMATION
DESCRIPTION
P R O C E D U R E , P O L IC Y ,
R U LE IN Q U E S T IO N
C IR C U M S T A N C E S
(description o f the
cand idate's actions,
tim ing, w itn ess accounts
if applicable, how it w as
brought to y o u r attention,
evidence, etc.)
A TTA CH A D D ITIO N A L SH EETS

A S REQ U IRED ,
Y O U R A C T IO N S
R E C O M M E N D A T IO N S
Office of the Fire Commissioner Page 1 of 1

November 2014

Page No.00125
Government E XA M /E V A LU A TIO N C H A N G E R EQ U EST
• A n y changes to an approved exam or evaluation m ust be m ade by co m p leting and su b m ittin g th is form , w hich m ust be
received by the O ffice of the Fire C o m m issio n er (OFC) prior to the original approved exam /evalu atio n date(s) and at least 2
W EEK S prior to the new testing date(s). S u b m it this form by em aii: ofc.certificationexam@Eov.ab.ca.
• Th e n ew testing date(s) m ust be w ithin G M O N TH S o f th e original testing date{s}.
• Changes to the num ber of can d id a te s being tested can be sub m itted in an em ail to o fc.ce rtifica tio n e xa m @ go v.ab .ca.
• A new exam an d /o r evaluation package w ill be shipped to th e p ro ctor/evaluator prior to the new te stin g date(s).
• Th e OFC may decline a change if this form is not co m p lete or if ail requirem ents have not been met.
T h is cotiecfion of personal information is necessary to support the certification and accreditation programs of the Office of the Fire Com m issioner. Th e collection is authorized
under Section 33(c) of the Freedom o f Information and Protection o f Privacy (FOIP) A ct and will be m anaged in accordance with the privacy provisions in the Act. If you have
questions regarding the collection of your personal information, please send your inquiry to the Office of the Fire Com m issioner, 16lh Floor, Commerce Place, 1 0 1 5 5 - 102nd
Street, Edmonton, AB, T 5 J 4L4 or emaii ofc,certificationexam@gov,ab.ca.
©2015 Office of the Fire Commissioner: www.ofc.alberta.ca

P age 1 of 1

Page No.00126
E VA LU A TO R A G R E E M E N T and E V A L U A T IO N RULES
fiovernm ent Hands-on Skills Evaluations
EVALUATOR AND TEST INFORMATION Please print clearly and D O N O T use initials.
Surname First Name Department (or individual) for whom you are evaluating
NFPA Standard Level Date of skills evaluation (mm/dd/yyyy)
EVALUATION PROCEDURES
The following evaluation procedures m u st be R E A D im m ed iately upon re c e iv in g y o u r e valuatio n p a ck a ge . Y o u m u st
F O L L O W all of the p ro c e d u re s listed here before, during and after the evaluation. After the evaluation, S IG N the d eclaratio n
confirming that you have read and followed all of these procedures. S U B M IT yo u r s ig n e d a gree m e n t with the completed
evaluation package.
Note that if you w ere in vo lved in the in stru ctio n o f the tra in in g fo r th is evaluatio n , you A R E N O T P E R M IT T E D to a ct a s an
evaluator. T h e fo llo w in g p ro c e d u re s a p p ly o n ly to h a n d s-o n s k ills e va lu a tio n s, not to a ss ig n m e n t-b a se d s k ills
e va lu a tio n s.
B E F O R E T H E E V A L U A T IO N D A T E
• Check that the evaluation package from the OFC contains the following items:
o Introductory letter
o Evaluator Agreement and Evaluation Rules (this document)
o Examination Record (summary of the Sets of Skills Posters sent and attendance form)
o A Set of Skills Posters for each candidate (used during the evaluation)
o Addressed return envelope.
• If any of these items are missing, contact the OFC immediately.

• Until the evaluation, keep the evaluation package in a secure, locked location to which only you have access.
• Read the information included in the evaluation package.
• Plan your evaluation based on the skills to be tested. Ensure you have the tools, equipment, PPE, facilities, and other
resources required to complete the evaluation.
• Check with the host department whether there are candidates with disabilities, and plan for any accommodations
that will need to be made.
• Check the facilities where the evaluation will be occurring to ensure it is a safe and healthy environment (e.g.,
temperature, air quality, lighting, space). If applicable, refer to NFPA 1403 Live Fire Training Standard, O ccupational
H ealth and S afety Act, R egulation a n d Code, and any local regulations, resolutions, municipal bylaws, and provincial
and/or federal legislation.
B E F O R E T H E E V A L U A T IO N B E G IN S
• Ensure that the evaluation area is laid out such that the candidates can be evaluated individually while the other
candidates are separated in a space where they cannot see or hear the evaluation,
• Provide time for the candidate to use the washroom facilities, remove any headgear (e.g., hats, headphones,
bandanas) and place personal items including cellphones in an area where they cannot be accessed during the
evaluation.
• Check the identification of all candidates and match them to the list provided by the training host.
• Read the E v a lu a tio n R u le s to the ca n d id a te before b e g in n in g the e valuatio n (see p age 3).
• Remember that you are responsible for the safety of the candidates. Check that each candidate has all the PPE
required and that it fits correctly. Check alt the equipment before it is used by the candidate to ensure it is safe and
ready for use.
Office of the Fire Com m issioner

www.ofc.aIberta.ca
November 2014
Page 1 of 3

Page No.00127
EVA LU A TO R A G R E EM EN T and E VA L U A T IO N RULES
Government Hands-on Skills Evaluations
DURING THE EVALUATION
• DO NOT allow any unauthorized person(s) to be present during the evaluation.

• Treat all candidates fairly and with respect. Discrimination against any candidate will not be tolerated. The Office of
the Fire Commissioner expects evaluators to treat all candidates in accordance with the C anadian Charter o f Rights
and Freedom s and the Alberta Human Rights Act.
• Remain objective when dealing with the candidates and considerate of their individual circumstances. Do not treat
any candidate preferentially or place any individual or group at a disadvantage compared to any other individual or
group. Treat all candidates as equally valued participants.
• DO NOT leave the candidate(s) alone while the evaluation is in progress.
• DO NOT provide any assistance or coaching to the candidates regarding the skills they are demonstrating, except
when their safety or the safety of others is at risk. If the candidate cannot demonstrate the skill without coaching, it
will be marked as “fail". If there is a safety concern, stop the evaluation immediately to address it.
• Candidates failing specific skill(s) may attempt the skill{s) a second time during the same scheduled evaluation.
• DO NOT allow any candidate to leave the evaluation facility during the evaluation, except at a scheduled break.
• Document the actions of any candidate who violates the Evaluation Rules (Exam/Evaluation Irregularity report) and
send your report to the OFC with the evaluation package.
A F T E R T H E E V A L U A T IO N
• Immediately after the evaluation, ensure all paperwork has been filled out and signed. Place the following items in the
return envelope:
o Signed Evaluator Agreement (this document)
o A signed and completed Set of Skills Posters for each candidate
o Completed Examination Record (attendance form)
o Completed Exam/Evaluation Irregularity report(s), if applicable.
• The evaluation package MUST be sent by courier to the OFC as soon as possible (within 24 hours) and no later than 48
hours after the evaluation. If the evaluations cannot be shipped immediately, ALL materials must be locked in a secure
location that only you can access. If a delay is necessary, the OFC must be advised of the reason for the delay an
estimated date of when the package will be sent.
DECLARATION
I , _______________________________________________________, have complied with all of the evaluation procedures listed

as specified by the Office of the Fire Commissioner and confirm that I have read these procedures before the start of the
evaluation. 1understand that failure to follow these procedures may result in suspension of my privileges as an instructor, proctor,
and evaluator for certification processes with the Office of the Fire Commissioner.
SIGNATURE DATE
QUESTIONS?
Email: ofc.certificationexam@gov.ab.ca
Website: www.ofc.alberta.ca
This collection of personal information is necessary to support the certification and accreditation program s of the Office of the Fire Com m issioner. Th e collection is
authorized under Section 33© of the Freedom o f Information a nd Protection o f Privacy (FOIP) Act and wili be m anaged in accordance with the privacy provisions in the
Act. If you have questions regarding the collection of your personal Information, please send your inquiry to the Office of the Fire Com m issioner, 16th Floor, Commerce
Place, 1 0 1 5 5 - 102"* Street, Edmonton, A B . T 5 J 4L4 or email ofc.certificationexam@ gov.ab.ca.

www.ofc.aiberta.ca
November 2014 Page 2 of 3

Page No.00128
EVA LU A TO R A G R E EM EN T and E V A L U A T IO N RULES
Hands-on Skills Evaluations
EVA LU A TIO N RULES

T H E E V A L U A T O R M U S T R E A D T H E F O L L O W IN G R U L E S T O T H E C A N D ID A T E S BEFORE
B E G IN N IN G T H E E V A L U A T IO N . ---------------
Hands-on Skill Evaluations
In fra c tio n s o f th e e v a lu a tio n ru le s w ill n o t be to le ra te d . If you v io la te th e s e ru le s, you w ill

be re q u ire d to le av e th e e v a lu a tio n a re a a n d w ill n o t be a llo w e d to c o m p le te th e e v a lu a tio n .
• The grading system is Pass or Fail. All tasks listed on the Skills Posters must be passed to
pass the evaluation.
• You must not leave the evaluation area once the evaluation has started. If you do, you will not
be allowed to continue.
• You must not communicate with others while you are being evaluated, except where it is part
of the task under evaluation. You must not coach other candidates while they are being
evaluated.
• No candidate is allowed to watch or listen to the evaluations of other candidates, unless

completing a team or partner task.
• Do not ask the evaluator to coach you. If you cannot complete the skill without coaching, it will
be marked as “fail”.
• if you are unable to complete the skill on your first attempt, you may be given a second
attempt, at the discretion of the evaluator.
• If at any time you feel that it is unsafe for you to demonstrate a skill, or if you have any other
safety concerns, inform the evaluator immediately.
• Once you have completed a skill, inform the evaluator.
• Turn off all cellphones and other electronics and place them and all other personal items
where they cannot be accessed during the evaluation.

www.ofc.alberta .ca
November 2014
Page 3 of 3

Page No.00129
A P P L IC A TIO N FOR T E S T IN G A C C O M M O D A TIO N S
Government To Accompany the Application to Host Training Form
P L E A S E ATTACH THIS APPLICATIO N TO YOUR APPLICATIO N TO HOST TRAINING FORM.
DEPARTM ENT AND TESTIN G INFORMATION (Piease printcieariy)

Host Department Name Contact Name (Last, First)
NFPA Standard and Level to be tested Date of testing (dd/mm/yyyyy) Written Exam □
Skills Evaluation □
CANDIDATE REQUIRING ACCOMMODATIONS (Please print clearly)

E-mail Contact Number (with area code)
ACCOM MODATION(S) REQUIRED I^ R e a d e r (fill out information below) □ Extra Time (1.5 times regular time)
Check all accommodations requested. P ] Scribe (fill out information below) f ^ Q u ie t Room
N O T E : It is th e r e s p o n s ib ilit y o f th e tr a in in g h o s t d e p a r t m e n t to m a k e a r r a n g e m e n t s fo r a c c o m m o d a t io n s .
DOCUMENTATION ATTACH ED □
Official medical or educational assessm ent documentation MUST be submitted with this application.
SCR IB E/R EA D ER INFORMATION Please print clearly. Refer to the requirements listed for Proctors on the Office of the Fire Commissioner website.
S urnam e F irst N am e M iddle Name
Shipping Address (for delivery by courier) Business Name (if shipping to a business)
Town / City Province / Territory Postal Code
Email Contact Number (with area code)
OFC USE ONLY
REVIEWED BY APPROVED BY
DATE DATE
EMAIL, MAIL OR FAX APPLICATION TO: QUESTIONS?

Office of the Fire Commissioner Email: ofc.certificationexam@gov.ab.ca
16mfloor. Commerce Place Website: www.ofc.alberta.ca
10155-102 Street
Edmonton, AB T5J 4L4
Fax: 780-644-5390
E-mail: ofc.certificationexam@gov.ab.ca
This collection of personal information is necessary to support the certification and accreditation programs of the Office of the Fire Commissioner. The collection is
authorized under Section 33(c) of the Freedom o f Information and Protection o f Privacy (FOIP)Act and wilt be managed in accordance with the privacy provisions in the Act.
If you have questions regarding the collection of your personal information, please send your inquiry to the Office of the Fire Commissioner, 16li’ Floor, Commerce Place,
10155—102nd Street, Edmonton, AB, T5J 4L4 or email ofc.certificationexam@gov.ab,ca.

www.ofc.aiberta.ca
September 2014 Alberta Municipal Affairs Information Request 201.5-RT0088
Page No.00130
y & t b e s tx ^ M A p p lica tio n to REW RITE EXAM
Governmeni NFPA C ertificatio n
• Rew rites are only granted to those stu d ents w ho scored 60% to 69% on the original exam .
• Rew rites m ust be rescheduled w ithin 60 DAYS of the original exam and m ust be received by the Office o f the Fire C om m ission er
2 W EEK S prior to th e rew rite date.
• Rew rite ap p lication s m ust be subm itted by the training h o st or approved training p rovider on behalf o f the student.
• Each stu d e n t m ust provide a w ritten explanation as to w hy he/she w as not successful during the o riginal exam ination, and w h at
steps he/she will take to receive a passing grade during th e rew rite.
HOST INFORMATION
Host Department Name Contact Name (first and last)
Approved Training Provider / School (if applicable) Contract # (if applicable)
REW RITE INFORMATION

Date of rescheduled exam Date of original exam
Total #
NFPA# L e v e l (e.g., Operations, Fire Fighter 1, Pumper) S tu d e n t s to R e w r ite (first and last names)
Exams
PR O CTO R INFORMATION
All pro cto rs m ust NOT have been involved in th e tra in in g and m ust NOT be related to , m arried to (legally or com m o n-la w ) o r o th e rw ise
personally associated w ith any o f th e candidates w ritin g th e exam. The exam package and P ro cto r A gre em e nt w ill be sen t to th e pro cto r.
Town / City Province/Territory Postal Code
INVOICE INFORMATION (May not apply to those testing through an approved training provider.)
A fte r the exams have been m arked, th e tra in in g host w ill be invoiced by em ail th ro u g h th e con tact person listed below . All stu d e n t
marks and scoring sum m aries w ill be sent a t th is tim e . The OFC w ill charge based on the to tal nu m b er o f exam s m arked.
Invoice Recipient Department/Company/School Contact Number !
( )
Email Purchase Order # / Contract #
Training hosts can pay fo r th e exams a fte r th e y have received th e invoice by m ailing a cheque o r m oney o rd e r payable to the
G ove rn m en t o f A lb erta OR by em ailing th e OFC to req ue st paym ent by cre d it card (th e OFC w ill send a link to a secure p a ym en t page).
O ffice of the Fire C o m m ission er em ail: o fc.certificatio n exam @ go v.ab .ca

16th floor. C om m erce Place
10155-102 Street
Edm onton, A B T5J 4L4
This collection of personal information is necessary to support the certification and accreditation programs of the Office of the Fire Commissioner. The collection is authorized under
Section 33(c) of the Freedom o f Information and Protection o f Privacy (FOIP) Acf and will be managed in accordance with the privacy provisions in the Act. If you have questions
regarding the collection of your personal information, please send your inquiry to the Office of the Fire Commissioner, 16th Floor, Commerce Place, 10 155- 102“ “ Street, Edmonton,
AB, T5J 4L4 or email ofc.certificationexam@gov.ab.ca.
©2015 Office of the Fire Commissioner; www.ofc.alberta.ca

Alberta Municipal Affairs Information Request 2015-^-0088 <1
Page N0 .OOI3 I
Government E X A M IN A T IO N FEEDBACK
PER SO N A L INFORMATION Please print dearly.
EXAMINATION INFORMATION
NFPA Standard and Level Exam ID Proctor Exam Date (mm/dd/yyyy)
FEED BA CK
Time taken to complete this form is not deducted from the time allotted to complete your examination. DO NOT WRITE OUT THE QUESTION.
You w ill NOT be contacted personally regarding the OFC’s review and response. Your feedback is appreciated and plays an important role in
maintaining fair and high quality examinations.
QUESTION #
ISSUE □ M u ltip le co rre ct answers C D No co rre ct answer listed
□ con fusin g o r am biguous □ Repeated question
1 I O ther:
EXPLANATION
QUESTION ft
ISSUE □ M u ltip le corre ct answers Q no correct answer listed
□ co n fu sin g o r am biguous □ Repeated question
□ O ther:
EXPLANATION
QUESTION#
ISSUE □ M u ltip le co rre ct answers □ no corre ct answ er listed
□ con fusin g o r am biguous □ Repeated question
□ o th e r:
EXPLANATION

Augusf 2014

Page No.00132
Government
EVA LU A TO R A P P L IC A TIO N
PER SO N A L INFORMATION P le a s e p rin t c le a rly an d D O N O T u s e in itia ls .

□ m ale D fem ale
Address
Town /C ity Province Postal Code Birthdate(mm/dd/yyyy)
Email Contact Number

( )
PR O FESSIO N A L INFORMATION (if retired, p le a s e in d ic a te y o u r p re v io u s D ep artm e n t, P o s itio n , R a n k , an d y e a r y o u retired .)
Fire Department Name Position Rank Retirement Year (if retired)
Have you attended the Office of the Fire Commissioner's Evaluator Course / Information Session? □Yes QNo
If you checked yes: Location Date (mm/dd/yyyy)
EVALUATO R DECLARATIO N
As an applicant to become an evaluator for the Office of the Fire Commissioner, please read and agree to the follow ing statements:
• I have successfully completed and received IFSAC / Pro Board certification for NFPA 1041 Level 2, and have attached copies of my certificates
as proof of completion (with seal number clearly visible).
• I will have successfully completed the NFPA level for the practical skills portion that I wilt be evaluating, and I will provide my transcript(s) and/or
copies of my certificate(s) as proof of completion (with seal number clearly visible).
• l will not apply to evaluate any NFPA levels for which I am not qualified.
• l will not be involved with the instruction of the NFPA tevel(s) I will be evaluating.
• i will not evaluate any person to whom I am related.
By signing below I confirm the above information is accurate and that I have read and agreed to the evaluator statements.
SIGNATURE DATE (mm/dd/yyyy)
EMAIL, MAIL, OR FAX APPLICATION TO:

QUESTIONS?
Office o f the Fire Commissioner Email: ofc.certificationexam@aov.ab.ca
16th floor, Commerce Place Website: www.ofc.alberta,ca
10155-102 Street
Fax: 780-644-5390
Email: ofc.certificationexam@aov.ab.ca
OFC USE ONLY:
REVIEWED APPROVED BY
DATE DATE
Section 33(e) of the Freedom of Information and Protection of Privacy (FOIP) Act and will be managed in accordance with the privacy provisions in Uie Act. If you have questions
regarding the collection of your personal information, please send yourinquiry to the Office of the Fire Commissioner, 16lh Floor, Commerce Place, 10155 - Street, Edmonton,
May 2015
Page 1 of 1
Page No.00133
A P P L IC A TIO N fo r 1031 and 1 0 3 3 O ut-of-province
Government
CERTIFICATE RECO GNITION
PER SO N A L INFORMATION P le a s e print c le a r ly an d D O N O T u s e in itia ls .

M A L E 0 FEMALE 0
Address
Town / City Province Postal Code Birthdate (mm/dd/yyyy)
L E V E L TO B E RECO G N IZED S e le c t the lev el fo r w h ic h y o u are a p p ly in g fo r re c o g n itio n .
J 1031 inspector Level 1 | | 1031 In sp ector Level il J 1033 Investigator

c
C O U R SES COM PLETED P le a s e in d ic a te th e c o u r s e s y o u h a v e c o m p le te d .
Inspector Levels 1& II and Investigator must take: inspector Levels 1& II and Investigator must take: 1nspeclor Level II and Investigator must take:
| |A lb erta Cod es and Standards j j Law fo r Fire S a fe ty Codes O fficers \ —1Courtroom and Legal Procedures for
— 1 Fire Safety Co d es O fficers
P L E A S E ATTACH
Transcripts fo r the above courses and copies of your Pro Board and IFSAC certificates for NFPA 1031 and/or 1033. Make sure that the seal
number is clearly visible.
PAYMENT INFORMATION
$30 per level. Please choose one of the following:
OcHEQUE Payable to Government of Alberta. Please include payment with the application.
0M O NEY order Payable to Government of Alberta. Please include payment with the application.
0C R E D 1TC A R D We will send you a link to a secure TD Payment Page to complete your payment.
Please provide your email: ____________________________________________________ (Please print dearly.)
0 IN V O IC E (H0St Department Only)

Contact Name Department / Company Purchase Order No.
Total Contact Number (with area code)

$
Address

www.ofc.alberta.ca
September 2014 Page 1 of 2

Page No.00134
DECLARATION
I confirm that all inform ation on this form is accurate and com plete in all respects. I shall comply with all rules and regulations of the
Office of the Fire Commissioner.
SIGNATURE____________ DATE
OFC USE ONLY:
REVIEWED BY: APPROVED BY:
DATE: DATE:
EMAIL, MAIL, OR FAX APPLICATION TO: QUESTIONS?

O ffice o f the Fire C o m m is sio n e r Em ail: ofc.certificationexam@oov.ab.ca
16lh floor, Commerce Place W ebsite: www.ofc.alberta.ca
10155-102 Street
Fax: 780-644-5390
Email; ofc.certificationexam@Qov.ab.ca
This collection of personal information is necessary to support the certification and accreditation programs of the Office of the Fire Commissioner. The collection is authorized
under Section 33(c) of the Freedom o f Information and Protection of Privacy (FOIP) Act and will be managed in accordance with the privacy provisions in the Act. If you have
questions regarding the collection of your personal information, please send your inquiry to the Office of the Fire Commissioner, 16th Floor, Commerce Place, 10155- 1 0 2 nd
Street, Edmonton, AB, T5J 4L4 or email ofc.certificationexam@gov.ab.ca.

www.ofc.alberta.ca
September 2014 page 2 of 2

Page No.00135
V a lid a tio n A g re e m e n t
Government Office of the Fire Commissioner
SESSION INFORMATION
Host Department Name of Team Lead Phone
NFPA Standard/Level under Review/Development Date of Review/Development (mm/dd/yyyy)
Textbook(s)
TEAM MEMBER INFORMATION

Name Department / Training Organization
Title/Rank Phone Email
N O T E : T h e fo llo w in g p ro to co ls m u st be read b y all m e m b e rs o f the exam review /developm ent team and e a ch
m e m b er is req u ire d to s ig n below .
TEA M L E A D
• The Team Lead will be responsible for:

o organizing and scheduling the review/development session
o ensuring all members of the team follow the protocols and have signed this agreement
o collecting all exam question material at the end of each meeting and ensuring it is kept in a secured
area
o collecting and submitting the new exam questions, signed agreements, sign in sheets, hand written
notes and all other related materials to the OFC.
R E V IE W / D E V E L O P M E N T TEA M
• The team must consist of members from at least two different fire departments.
• Each member of the team must have successfully completed 1041 Instructor Level I and the Standard and
Level under review.
EX A M Q U E S T IO N S
• All exam questions created by the team are property of the Office of the Fire Commissioner and shall not be
removed or copied and retained or distributed.
• Each question must relate to the specific context of a JPR and line from the correlation sheet (e g., a, b, c ...).
• Each question must refer to content found on a page of the assigned textbook(s).
• Each question must be developed based on the Exam Question Criteria provided by the OFC (see next
page).
DECLARATION
I,_______________________________________________________ , understand and will comply with all of the

protocols as specified by the Office of the Fire Commissioner.
SIGNATURE DATE

April 2015 1

Page No.00136
V a lid a tio n A g re e m e n t
E x a m Q u e s tio n C r ite r ia
* CORRELATED: Ensure ail exam questions meet the intent of the NFPA Standard/Level.
* CORRECT: Ensure that the question is correct and the distractors are legitimate within an
Alberta context.
* COVERAGE: Ensure there are at least two unique exam questions per line in the correlation
sheet.
* TEXTBOOK: Ensure the answers to the exam questions are found in the selected textbook.
* WRITING: Ensure the exam questions are written in a clear and straightforward manner.
Q u e s t io n s c a n b e m u lt ip le c h o ic e w ith 4 c h o ic e s . Use "all of the above” and "none of the above”

sparingly and they should not always be the correct answer. Avoid throw away distractors. Keep all
distractors about the same length, if possible. Try to keep all distractors in the same category (e.g., all
instructions, all tools, all descriptions). A ll choices should work grammatically with the stem.
Q u e s t io n s c a n b e T r u e / F a ls e . True should not always be the correct answer.
Focus on ...
• addressing the intent of the JPR (ask: "What am I assessing with this question?")
• avoiding any possible confusion or ambiguity, e.g., multiple correct answers
• being careful about value judgments, e.g., the most im portant___ , as they may be scenario
dependent
• using simple, direct, active language
• using a voice and tone that are formal and professional.
The OFC will focus on ...

• style, formatting, punctuation and spelling
• ensuring all questions are grammatically correct
• double-checking the textbook references
• ensuring that each question is a good match to the JPR.

April 2015 2

Page No.00137
^ 4 ib e 4 & a i
Government T R A N S C R IP T R EQ U EST
PERSONAL INFORMATION P le a s e p rin t c le a r ly an d D O N O T u s e in itiats.

Q m ale O fem ale
Address
Town / City Province Postal Code Birth date (mm/dd/yyyy)
THIRD PARTY INFORMATION P le a s e p rin t c le a r ly a n d D O N O T u s e in itia ls.

C o m p le te th is s e c t io n o n ly if a th ird p a rty p e rs o n / o rg a n iz a tio n re q u ire s y o u r tra n s c r ip t to b e m aile d d ire c t to them .
Contact Name
Address Organization
Town / City Province Postal Code
DECLARATION
I,, confirm that all information on this form is true and complete in all respects. By signing this
declaration, I permit the Office of the Fire Commissioner to release my transcript to the third party listed above. If the third party information
section has been left incomplete, my transcript will be mailed to the address listed under personal information.
SIGNATURE DATE

O ffice o f the F ire C o m m is sio n e r Email: ofc.certificationexam@Qov.ab.ca
16ib floor, Commerce Place Website: www.ofc.alberta.ca
10155-102 Street
Fax: 780-644-5390
Email: ofc.certiticationexam @ gov.ab.ca
This collection of personal information is necessary to support the certification and accreditation programs of the Office of toe Fire Commissioner. The collection is authorized under
Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act and will be managed in accordance with the privacy provisions in the Act. If you have questions
regarding toe collection of your personal information, please send your inquiry to the Office of toe Fire Commissioner, 16s' Floor, Commerce Place, 10155 - 102M Street, Edmonton, AB,
T5J 4L4 or email ofc.certificationexam@gov.ab.ca.

www.ofc.alberta.ca
July 2014 Alberta Municipal Affairs Information Request 2015-R-0088, r 1
Page No.00138
PROCTOR A G R E E M E N T and EXAM RULES
Government W ritten Exams
PROCTOR AND EXAM INFORMATION P le a s e p rin t c le a rly a n d D O N O T u s e in itia ls.
Surname First Name Department for whom you are proctoring
Address Email Phone
NFPA Standard Level Date of exam {mm/dd/yyyy)
PROCTOR EXAMINATION PROCEDURES
The following procedures m u st be R E A D im m ed iately upon re ce iv in g yo u r e xa m p a ck a g e . Yo u m u st F O L L O W all of the

p ro c e d u re s listed here. S IG N the d ecla ra tio n confirming that you have read and followed all of these procedures. S U B M IT y o u r
sig n e d a gree m e n t with the completed examination package.
B E F O R E T H E EXA M D A T E
• Check that the proctor package contains the following items:

o Introductory letter
o Examination Record Form (summary of the exams sent and attendance form)
o Proctor Agreement and Exam Rules (this document)
o Student answer sheets, instructions for completing answer sheets, and envelope for completed answer sheets
o Sealed envelope containing exam booklets
o Addressed return envelope.
• if any of these items are missing, contact the OFC immediately.
« Open the envelope with the exam booklets upon receipt and check that the exam type and number are correct. If
there are any discrepancies, contact the OFC immediately. After the exams have been verified, reseal the envelope
until the start time of the exam. Keep the exams in a secure, locked location to which only you have access.
• Check the facility where the exam will be written to ensure it is a safe and healthy environment for testing (e.g.,
temperature, air quality, lighting, space, exits, adequate number of desks/chairs).
• If the host department has indicated that there are candidates with disabilities that have been declared and
accommodated during training, ensure the appropriate accommodations can be applied during testing. If a candidate
has not declared a need for accommodation before training (training application), accommodations cannot be made
during testing.
• Throughout the examination process, treat all candidates fairly and with respect. Discrimination against any
candidate will not be tolerated. The Office of the Fire Commissioner expects proctors to treat all candidates in
accordance with the C anadian C harter o f Rights and Freedom s and the A lberta H um an R ights Act.
B E F O R E T H E EX A M B E G IN S
• Ensure that the only objects on or near all desks and chairs are the exam booklets, exam feedback form, answer
sheets, blank scratch paper, two HB pencils, eraser and the permitted reference material specified on page 2 of the
exam booklet.
• Check that there is adequate spacing between desks so that the candidates cannot copy each other’s work.
• Have the candidates sign in as they arrive. If there are more candidates than exam booklets, contact the host
department and the OFC to reschedule an exam for the extra students. DO NOT COPY the exam booklets or allow
candidates to share. If candidates miss the scheduled exam, they must apply for a rewrite.
• Check the identification of all candidates and match them to the list provided by the training host.
• Explain to the candidates how to complete the answer sheets. Refer to the Instructions for Completing Examination
Card. Candidates must enter their complete name, birthdate, and gender. Remind candidates that any incompletely
filled out or crossed out answers will be marked as incorrect by the computer. Emphasize that they must completely
fill one circle per question and completely erase any other marks on the answer sheet. The OFC will not hand mark
exam answer sheets that are unreadable by machine due to candidate error.

May 2015
Page 1 of 3

Page No.00139
PROCTOR A G R E EM EN T and EXAM RULES
Government _________________________________Written Exams
• Provide time for the candidates to use the washroom facilities, clear their desks, remove any headgear (e.g.r hats,
headphones, bandanas) and place personal items including backpacks, cellphones where they cannot be accessed
during testing.
• R ead the E x a m R u le s to the c a n d id a te s before the start o f the exam (see p a g e 3).
• Ensure that the candidates complete, sign, and date the Examination Registration stapled to the front of each exam
booklet.
D U R IN G T H E EXA M
• Remain objective when dealing with the candidates and considerate of their individual circumstances. Do not treat
any candidate preferentially or place any individual or group at a disadvantage compared to any other individual or
group. Treat all candidates as equally valued participants.
• DO NOT allow any unauthorized person(s) to enter the room or be present during the exam.
• DO NOT leave the room while the exam is in progress.
• DO NOT provide any assistance or coaching to the candidates regarding the content of the examquestions.
• Any candidate who leaves the exam room for any reason during the exam will not be allowedto re-enter and will not
be allowed to complete the exam.
• Ask any candidate who violates the Exam Rules to leave the room. Document the candidate’s actions and send your
report to the OFC with the exam package.
• Collect the exam booklets as the candidates finish the exam or at the scheduled end of the exam. Make sure all
candidates’ Registration Forms are correctly filled out (e.g., name, birthdate, gender, exam name).
• Ten minutes before the exam is scheduled to end, give the candidates a warning. Ensure all exams have been
turned in to you at the end of the scheduled time.
A F T E R T H E EXAM
• Provide time after the candidates have submitted their exam answer sheets to complete exam feedback forms, if they
wish to do so. Provide the candidates with a copy of the exam for reference (but not their answer sheets) when they
complete their exam feedback forms and ensure all exams are returned. Collect the feedback forms after they have been
completed and submit them to the OFC with the exam package.
• Immediately after the exam, ensure all paperwork has been filled out and signed. Place the following items in the return
envelope:
o Completed Examination Record Form (attendance form)
o All exam booklets (used or unused) with attached Examination Registrations (cover sheets)
o Student answer sheets (in sealed envelope)
o Signed and dated Proctor Agreement (this document)
o Other documents associated with the examination (e.g., Exam Feedback forms, Exam/Evaluation Irregularity reports)
• DO NOT keep any extra copies or reproductions of the exam, in full or in part.
• The exam package MUST be sent by courier to the OFC as soon as possible (within 24 hours) and no later than 48 hours
after the exam. If the exams cannot be shipped immediately, ALL materials must be locked in a secure location that only
you can access until they are returned to the OFC. If a delay is necessary, The OFC must be advised of the reason for
the delay and provided an estimated date of when the package will be sent.
DECLARATION
I . ______________________________________________________________ _ have complied with all o f the exam ination procedures listed
in this agreement. I understand that failure to follow these procedures may result in suspension of my duties as an instructor,
proctor, and evaluator fo r certification processes with the Office o f the Fire C om m issioner. I also confirm that the following
statem ents are true:
• I am a m em ber in good standing in the com m unity.
• I have not been involved with the instruction o f the NFPA level for the exam ination that I am proctoring.
• I will not proctor an exam for any person to whom ! am related, by birth or marriage.
• I will not proctor an exam and then take the exam as a candidate within one year.
SIGNATURE_______________________________________________ DATE_________________________________________________________

May 2015 Page 2 of 3

Page No.00140
PROCTOR A G R E EM EN T and EXAM RULES
Government W ritten Exams
EXAM RULES
THE PROCTOR MUST READ THE FOLLOWING RULES TO THE CANDIDATES BEFORE
BEGINNING THE EXAM. ------------
Infractions of the exam rules will not be tolerated. If you violate these rules, you will be
required to leave the exam area and will not be allowed to complete the exam.
• The passing grade for this exam is 70%.

• You have_____minutes to complete the exam. (See page 1 of the exam booklet.)
• Fill in the following information before you begin:
o Examination Registration on the front of the exam
o the name of the exam and the version number at the top of the answer sheet
o your name (last name, first name) and birth date written in the boxes AND coloured in each
corresponding circle on the answer sheet.
• Do not write in the exam booklet unless you are told you can.
• The only objects that you can have on your desk are: the exam booklet, answer sheet, blank scratch paper,
two HB pencils, eraser and the permitted reference material specified on page 2 of the exam booklet.
• Turn off all cellphones and place them at the back of the exam room. Cellphones cannot be used as a
calculator.
• Place all other personal items at the back of the exam room. You must not wear any headgear, sunglasses,
visors, or hoodies.
• Do not leave the room once the exam has started. If you do, you will not be allowed back in and will have to
apply to rewrite the exam.
• Do not communicate with other candidates during the exam. Do not look at the exam papers of any other
candidates. All work on the exam must be your own. If you are suspected of cheating, you will not be allowed
to complete the exam and the proctor will report the circumstances to the OFC for investigation.
• If you have a concern, raise your hand and the proctor will come to your desk. Do not ask the proctor to
explain any exam questions or to help you with the answers.
• Read each question carefully and mark your responses clearly on the answer sheet with an HB pencil only.
The computer cannot read responses made by any other pencils or pens. Any incompletely filled out or
crossed out answers will be marked as incorrect by the computer. You must completely fill one circle per
question and completely erase any other marks on the answer sheet. The OFC will not hand mark exam
answer sheets that are unreadable by machine due to candidate error.
• Mark A for true answers. Mark B for false answers.
• Hand in the entire exam booklet, answer sheet, exam feedback, and any scratch paper to the proctor when
you have finished the exam, or when the proctor calls time.
• After all exams have been returned to the proctor, you will be provided time to complete an Exam Feedback
form if you wish to do so.
Office of the Fife Commissioner

May 2015
Page 3 of 3

Page No.00141
A p p lic a tio n to H O S T T R A IN IN G
y^liaeAbc^M NFPA Certification
Government
• A p p licatio n s m ust be received by th e O ffice o f the Fire C o m m issio n e r (OFC) at least O N E M ONTH (30 DAYS) prior to the
exam /evalu ation date(s). Please su b m it one form for each N FPA standard/level. The O FC m ay d eclin e an a p p lication if it is not
co m p le te or if all req u irem ents have not been met.
• All testing m ust o ccu r on a site th at has been approved by the OFC,
• B efore applying, review N FPA Standard A vailab ility on th e O FC's w ebsite. Note w h e th e r the level you w ish to host is available
o r due to be revised during yo u r proposed trainin g period.
• R eview th e instructor, proctor and evaluato r req u ire m e n ts posted on the OFC w ebsite prior to co m p le tin g this application.
• If a change is required fo r the testing date o r in th e n u m b er o f stu d ents, please com p lete and subm it an Exam /Evaluation
Ch ange Request form to the OFC at least 2 W EEK S prior to the exam /evalu atio n date.
• The trainin g host's resp o n sib ilities have been listed in th e attached Train ing Host A greem en t {pages 3 and 4 o f this docum ent).
This agree m e nt m ust be signed prior to th e application being approved.
Section 33(c) of the Freedom o f Information and Protection of Privacy (FOtP) Act and will be managed in accordance with the privacy provisions in the Act. If you have questions
regarding the collection of your personal information, please send your inquiry to the Office of the Fire Commissioner, 16th Floor, Commerce Place, 10155 - 102^ Street, Edmonton,

Alberta Municipal Affairs Information Request (2P15rR-0088
Page NO.00142
LEAD INSTRUCTOR INFORMATION
All lead instructors must have successfully completed {1) the training level they w ill be teaching and (2) NFPA 1041 Fire Service Instructor Level I. If
not currently an approved instructor with the OFC, please include proof of qualification with this application. The instructor CANNOT act as the
proctor or evaluator. An instructor package and instructor Agreement w ill be sent by email to the training host contact.
First Name Middle Name Last Name Birth Date
Address
EVALUATOR INFORMATION
A ll eva luato rs m u st have s u c c e s s fu lly com p leted (1) the tra in in g level they w ill be eva lu atin g and (2) N F P A 1041 Fire S e rv ice Instructor Leve l II. If
not cu rre n tly an approved evaluator w ith the O FC , ple a se in c lu d e p ro o f o f q u a lifica tio n w ith th is ap p licatio n . The evaluation package and E va lu ato r
A gree m en t w ill be sent to the evaluator listed below.
First Name Middle Name Last Name Birth Date
PROCTOR INFORMATION sam e AS evaluato r Q~j

A ll p ro cto rs m u st NOT have been in vo lved in the training and m ust NOT be related to, m arried to (leg ally o r com m on-law ) or o th e rw ise p e rso n a lly
a s so c ia te d w ith any of the can d idate s w riting the exam . The exam pa cka ge and P ro cto r A greem ent w ill be sent to the p ro cto r liste d below .
First Name Middle Name Last Name
INVOICE INFORMATION (May not apply to those testing through an approved training provider.)
COST PER EXAM
TOTAL# CANDIDATES TOTAL DUE
$45 (OR $35 if 20 or more)
@ = $
After the exams have been marked, the training host will be invoiced by email through the contact person listed below. All student marks
and scoring summaries will be sent at this time. The O FC w ill ch arge based on th e to ta l num ber o f exam s m arked. A n exam w ill not be
m arked if a can d id ate has not su ccessfu lly passed th e skill evaluation.
Invoice Recipient Department / Company / School Contact Number
< )
Email Purchase Order # / Contract #
Training hosts can pay for the exams after they have received the invoice by mailing a cheque or money order payable to the Government
of Alberta OR by emailing the OFC to request payment by credit card (the OFC will send a link to a secure payment page).
O ffice of th e Fire C o m m issio n er em ail: o fc.ce rtifica tio n e xa m (Sgo v.a b .ca
16 floor, C om m erce Place
10155-102 Street
Edm onton, AB T5J 4L4

Alberta Municipal Affairs Information Request3015-jR-0088
Page No.00143
T R A IN IN G H O ST A G R E E M E N T
Government NFPA Certification
TRAINING HOST
Fire Department or Approved Training Provider Contact Name (first and last)
TRAINING HOST RESPONSIBILITIES

A pproved hosts o f OFC N FPA certification e xam s/evaiu atio n s are resp o n sib le for ensu rin g all O FC req u irem ents have been met.
A rep resen tative of the O FC m ay, w ith o u t notice, visit y o u r testing site to ensu re all req u ire m e nts have been met.
A P PLICA TIO N S A N D SCH ED U LIN G
• Training hosts are expected to follow all timelines and processes related to applications to host training, rewrites,
rescheduling and appeals and indicated on the OFC website: www.ofc.alberta.ca/fire-rescue-service-certification.
• The training host is solely responsible for the scheduling of training and testing and for informing students and the OFC of
any changes to the schedule.
• To reschedule or otherwise change your training/testing, complete and submit an Exam/Evaluation Change Request form.
IN STRU CTIO N
« JPRs: All of the NFPA Standard Job Performance Requirements (JPRs) for the level must be covered during instruction in
preparation for assessment.
• INSTRUCTOR QUALIFICATIONS: instructors must be qualified as per OFC requirements. All training for certification must be
led by a qualified instructor who provides feedback to students as required. At no time can the instructor participate in the
proctoring of the exam or the evaluation of the skills. Instructors must read and sign an Instructor Agreement.
• ONLINE CONTENT: Online content can be used as part of the training, but the course must be moderated and facilitated by
a qualified instructor. Skills instruction should be hands on and requires regular coaching, feedback and mentoring.
• TEXTBOOKS: it is the training host's responsibility to select the textbook and any other resources used during training. The
OFC is not responsible for differences between the text used to validate the exam and the resources used by the training
host.
FACILITY/SITE
• SITE INSPECTION: An OFC site inspection must be completed for the testing site by a qualified third-party external to the
organization.
• TRAINING SITE REQUIREMENTS: Training site owners must ensure the following requirements have been met.
o All fire training facilities (including structures, props, trenches, confined spaces, rappelling walls, etc.) should
conform to NFPA 1402 Guide to Building Fire Service Training Centers and O ccupational H ealth a n d S afety Act,
R egulation a n d Code. Some new structures may require an engineering inspection and report, as decided by the
authority having jurisdiction.
o Training site owners must consult with the appropriate authority having jurisdiction to ensure all of the necessary
permits (building, electrical, gas) have been acquired. Those municipalities that do not require permits for fire
training structures must provide a written declaration of exemption,
o Any gas or electric props built out-of-country must be certified for use in Canada/province of Alberta,
o All facilities using live fire must conform to the requirements of NFPA 1403 Live Fire Training Evolutions,
o Those training hosts proposing to use an acquired structure during an evaluation for certification will require an
inspection by a representative of the OFC prior to testing,
o All training sites should be inspected by qualified personnel on an annual basis.
©2015 Office of the Fire Commissioner; www.ofc.alberta.ca

Alberta Municipal Affairs Information Request. 2015-R-0088
P’a geNo.b0144
• TOOLS, EQUIPMENT AND PROPS: There must be sufficient tools, equipment and props to accommodate all students and to
address all the required skills for the Standard/Level. All tools, equipment and props must be properly maintained and in
good working order.
• HEALTH AND SAFETY: A safe and healthy environment must be maintained, including such things as temperature, air
quality, lighting, space, cleanliness and tidiness. All testing must comply to O ccupational H ealth and S afety Act, Regulation
and Code and any local regulations, resolutions, municipal bylaws, and provincial and/or federal legislation, including
environmental legislation. All existing and potential hazards must be identified and addressed (e,g„ electrical, mechanical,
atmospheric, weather) by a designated safety officer. The evaluator can, at any time, stop an evaluation so that his/her
concerns or hazards identified can be addressed.
• INSPECTION: A walkthrough of the testing site should be conducted prior to the scheduled start time by a representative of
the facility or other qualified personnel.
TESTIN G
• TESTING MATERIALS: All testing materials supplied to the training host are the property of the OFC and may not be
reproduced or distributed beyond their administration. Completed exams and evaluations must be kept securely and
privately until they have been returned to the OFC.
• LIVE FIRE: All live fire testing must comply to NFPA 1403 Live Fire Training Evolutions.
• OBJECTIVITY: Skills evaluations must be completed in an objective manner and training hosts must avoid any potential
conflicts of interest in the evaluation of candidates. Evaluators must not be pressured or otherwise influenced in any way that
interferes with their ability to act as an agent of the OFC independent of the training host.
• EVALUATORS AND PROCTORS: Evaluators and proctors must be qualified as per OFC requirements, see
www.ofc.alberta.ca/certification-instructor-proctor-and-evaluator-reauirements. It the responsibility of the training host
to ensure the Evaluator and Proctor Agreements are read, followed and signed.
• RETESTING: Students should be accommodated to retest a skill, at the discretion of the evaluator, within a reasonable
amount of time during the same evaluation session. Exam rewrites for qualified students must be scheduled through the
OFC. For more information see www.ofc,alberta,ca/certification-rewriting-exam-skills-evaluation.
DECLARATION
I . ______________________ _______________________________ , ensure that I have read the requirements specified by the OFC and
that the training host will comply with these requirements. I understand that failure to follow these requirements may result in the
suspension of the NFPA certification privileges of the training host with the Alberta Office of the Fire Commissioner.
SIGNATURE DATE
QUESTIONS?
E m ail: o fc.ce rtifica tio n exam @ qov,ah ,ca

W ebsite: w w w .ofc.alberta.ca
©2015 Office of the Fire Commissioner: www.ofc.alber1a.ca

Page No.00145
A P P L IC A T IO N to C H A LLEN G E NFPA 1081 LEVELS
Government Incipient, Advanced Exterior, and In terio r S tructural
A P P L IC A T IO N S M U S T B E R E C E IV E D B Y T H E O F C A T L E A S T O N E M O N T H P R IO R T O T H E P R O P O S E D E X A M / E V A L U A T IO N D A T E .
DEPARTMENT INFORMATION Please print clearly.

Host Department Name Contact Name
Address
Contact Email Contact Number (with area code)
TESTING INFORMATION Please print clearly.

Number of Candidates
Written Examination Date (mm/dd/yyyy)

Level to be Tested
Incipient
n
Practical Evaluation Date (mm/dd/yyyy)
A d v a n ce d E xterior
□ Interior S tructural
□
Practical Skills Evaluation Site Location Approved Site?
YES
CANDIDATE INFORMATION Please print clearly. DO NOT use initials. Certificate/T ra nscript?
1 Surname First Name Middle Name Birth Date
YES
YES
YES
YES
YES
YES
YES
YES
YE S
YES
YES
YES
YES
YES
YES
PLEASE ATTACH FOR EACH CANDIDATE

O ffic ia l tra n sc rip ts for 1001 le ve ls 1 and 2 and 472 A w a re n e ss O R c o p ie s o f P ro B oard /1 F S A C c e rtific a te s fo r N F P A 1001 L e v e ls 1 and 2. M ake su re
that the seal n u m b e rs are cle a rly v isib le . _____________________ ________________________________________________________________________
Alberta Office of the Fire Commissioner: www.ofc.alberta.ca

August 2015
Alberta Municipal Affairs Information Request 2015-R-0P88.3
Page No.00'146
A P P L IC A TIO N to CHALLENGE NFPA 1081 LEVELS
y ^ d h e ttfa M
GcvernmGnt Incipient, Advanced Exterior, and In terior Structural
EVALUATOR INFORMATION Please print clearly. Refer to the requirements listed on the Office of the Fire Commissioner website. I
Shipping Address Business Name (if shipping to a business)
AStached transcripts/certilicates for NFPA 1041 Level II and 1081 applicable level(s). Ves No
PROCTOR INFORMATION Please print clearly. Refer to the requirements listed on the Office of the Fire Commissioner website.
PAYMENT INFORMATION
$175 per person per level (includes exam and evaluation)
Please choose one of the following:

j__(CHEQUE Payable to Government o f Alberta Please include payment with your application. ■
.. ...
;|_ |money order Payable to Government of Alberta Please include payment with your application. I
— ____________________________________________________________________________ _
|__[CREDIT CARD We will send you a link to a secure TD payment page to complete your payment. j
Please provide vour email: (please print clearlv) \

L—--------------------------------------------------------------------------------------------------------- " ' ** S
■Q lN V O IC E !
Contact Name Department / Company Purchase Order No.
Total Contact Number (with area code)

$
Address ;
| Town / City Province / Territory Postal Code I
HOST DEPARTMENT DECLARATION

On behalf of the host department for which this application was submitted, I confirm that all information on this form is accurate and complete
in all respects.
SIGNATURE DATE
NAME (print) RANK RELATIONSHIP TO HOST DEPARTMENT
Alberta Office of the Fire Commissioner: www.ofc.alberta.ca

August 2015
Alberta Municipal Affairs Information Request 2015-R-0088 ■
Page No.00147
A P P L IC A TIO N to CHALLENGE NFPA 1081 LEVELS
Government Incipient, Advanced Exterior, and In terio r Structural
OFC USE ONLY:
REVIEWED BY: APPROVED BY:
DATE: DATE:

O ffice o f the Fire C o m m is sio n e r Em ail: ofc.certificationexam@aov.ab.ca
16lh floor, Commerce Place W ebsite: www.ofc.alberta.ca
10155-102 Street
Fax: 780-644-5390
E m ail: ofc.certificationexam@aov.ab.ca
Section 33(c) o f the Freedom o f Information and Protection o f Privacy (FOIP) Act and wilt be managed in accordance with the privacy provisions in the Act. If you have questions
regarding the collection of your personal information, please send your inquiry to the Office of the Fire Commissioner, 16" Floor, Commerce Place, 1 0 1 5 5 -102"11Street, Edmonton, AB,
T5J 4L4 or email ofc.certific8tionexam@gov.ab.ca.
Alberta Office of the Fire Commissioner: www.ofc.elberta.ca

August 2015
Alberta Municipal Affairs Information Request 201 ■ ■
Page No.00148
A P P L IC A TIO N fo r C E R T IF IC A T IO N
Governmeni NFPA S tan d ard and Level
TH E O FFICE OF TH E FIRE CO M M ISSIO N ER DOES NO T O FFER C ER TIFICA TIO N FO R TR A IN IN G C O M PLETED 10 YEA RS O R M ORE PRIO R
TO TH E DATE TH IS A P P LIC A TIO N IS RECEIVED . For more information, see www.ofc.alberta.ca/applving-for-certificate-or-replacement.
I N D IV ID U A L IN F O R M A T IO N Please print clearly.

Surname First Name Middle Name Previous Name (If applicable)
Address
□ m ale D fem ale
Town / City Province/Territory Postal Code Birthdate (mm/dd/yyyy)
Email Contact Number

( )
P LEA SE CH O O SE:
Q N e w Certificate(s) ($30 each) ^ R e is s u e d C ertificate(s) ($130 each)
Note: Not all NFPA levels are available for certificates from both Boards. If certification for your preferred Board is not available, a certificate will
automatically be generated for the other Board.
IF S A C P ro B o a rd B o th
N FPA# L e v e l (e.g., Operations, Fire Fighter I, Trench Rescue II, Pumper)
certificate certificate certificate s
T O T A L # C E R T IF IC A T E S
It is th e resp on sib ility o f the a p p lican t to include pro o f o f com pletion o f all req u irem ents fo r certification - see the N FPA
Certificate R e qu irem e n ts d ocu m en t available on w w w .o fc.a lb erta .ca /a p p lyin g-fo r-ce rtifica te-o r-re p la cem en t.
Proof of certification includes:
• Copies of certificates (from Alberta or out-of-province)
• Official transcripts from an approved training provider
• Copies of EMT/EMR/paramedic/Advanced First Aid or Standard First Aid qualifications
Do n o t send original d o cu m en ts to the OFC as th e y will not be returned.
In com p lete ap p licatio n s will be declined and the ap p lican t w ill be required to re-apply.
Certificate s w ill not be issued until paym ent has been received by the OFC.
If an ap p lication fo r certification is found to have been com p leted frau d u le n tly, th e O FC m ay refuse an y futu re certification of
the in d ivid u al or trainin g host.

Page No.00149
INDIVIDUAL PAYMENT INFORMATION
COST PER CERTIFICATE
TOTAL# CERTIFICATES TOTAL DUE
New $30 OR Reissued $130
= $
@
r “ j A P P L Y IN G B Y M A IL
'— ‘ W hen applying by m ail, applicants m ust send pa ym en t in th e fo rm o f a cheque o r m oney ord e r (payable to th e G ove rn m en t o f
A lb e rta ) w ith th e application._______________________________
M ail com p leted ap p licatio n s w ith cheque o r m oney o rd er to:
O ffice o f th e Fire C om m issioner

16th flo o r, C om m erce Place
10155-102 S treet
E dm onton, AB T5J 4L4
A P P L Y IN G B Y E M A IL
W hen applying by em ail, applicants m ust pay by cre d it card. Once y o u r a p plicatio n has been approved, w e w ill rep ly to you r
em ail w ith a link to a secure TD Paym ent Page to com p le te y o u r paym ent.
All certificates w ill be sent to the individual a p p licant's m ailing a d d ress listed on the first page of th is form .
TRAINING HOST PAYMENT INFORMATION

COST PER CERTIFICATE
TOTAL# CERTIFICATES TOTAL DUE
New $30 OR Reissued $130
= $
T raining hosts applying fo r c e rtifica te s fo r stud ents w ill be invoiced th ro u g h th e con tact person at th e address provided below.
T raining hosts may pay fo r certifica te s by m ailing cheques o r m oney orders OR by em ailing th e OFC to req ue st p a ym en t by cre d it card
and th e OFC w ill send a link to a secure TD cre d it card p a ym en t page. All ce rtifica te s w ill be sent to th e tra in in g host fo r d is trib u tio n
to th e in d ivid u a l applicants.
Contact Name Department / Company Contact Number
( )
Email PO #
Address
M ail cheque or m o n ey order p ayable to th e G o vern m en t of A lberta to:
O ffice o f th e Fire Com m issioner

16!h flo o r, C om m erce Place
10155-102 S treet
E dm onton, AB T5J 4L4
O FC USE O N LY
C o n t a c t th e O ffic e o f t h e Fire C o m m is s io n e r : o fc .c e rtific a tio n e x a m (5 > g o v .a b .c a

This collection of personal information is necessary to support the certification and accreditation programs of the Office of the Fire Commissioner. The collection is authorized
under Section 33(c) of the Freedom o f Information and Protection o f Privacy (FOIP) Act and will be managed in accordance with the privacy provisions in the Act. If you have
questions regarding the collection of your personal information, please send your inquiry to the Office of the Fire Commissioner, 16“' Floor, Commerce Place, 10155 - 102"11
Street, Edmonton, AB, T5J 4L4 or email ofc.certificationexam@gov.ab.ca.
©2015 Office of the Fire Commissioner Alberta Municipal Affairs Information Request 20jl5:-R-Q.Q68
Page No.00150
^ 4 dhwbc^M A P P L IC A TIO N to APPEAL
Government
In e x c e p t io n a l c ir c u m s ta n c e s , c a n d id a te s m a y a p p e a l to r e a t t e m p t a w r itte n e x a m in a t io n o r s k ills e v a lu a t io n if th e
o r ig in a l m a r k is le ss th a n G 0% o r " F a il" . A c a n d id a te m a y a ls o a p p e a l an u n s u c c e s s fu l re w rite . A n a p p e a l m u s t be r e c e iv e d
b y th e O ffic e o f t h e F ire C o m m is s io n e r w ith in 6 0 d a y s o f th e o r ig in a l te s t in g d a te .
P E R S O N A L IN F O R M A T IO N
Surname First Name Middle Name Previous Name (If applicable)
Address
Town / City Province / Territory Postal Code Birthdate (mm/dd/yyyy)
T E S T I N G IN F O R M A T IO N
Date you were originally tested Grade Attained NFPA Standard Level
Instructor's Name Training Flost/School
EXAM A P P E A L E V A L U A T IO N A P P E A L
Proctor's Name Evaluator's Name
W R IT T E N E X P L A N A T IO N
It is m a n d a t o r y th a t y o u a tta c h a w r it te n e x p la n a t io n as to w h y y o u w e r e u n s u c c e s s fu l (in c lu d e s p e c ific d e t a ils a n d

e v id e n c e to s u p p o r t y o u r s to ry ), w h y y o u t h in k y o u d e s e r v e a r e w rite , a n d th e m e a s u r e s y o u w ill ta k e to e n s u r e y o u a re
s u c c e s s fu l o n y o u r re w rite .
___________________________________________________________________________________________________
E M A I L O R M A IL A P P L I C A T I O N T O : Q U E S T IO N S ?
O ffice of the Fire C o m m is s io n e r W ebsite: www.ofc.alberta.ca

16111floor, Commerce Place
10155-102 Street
E m ail: o fc.ce rtifica tio n e xa m @ q o v .a b .ca
This collection of personal information is necessary to support the certification and accreditation programs of the Office of fhe Fire Commissioner. The collection is authorized under
Section 33(c) of the Freedom o f Information and Protection of Privacy (FOIP) Act anti will be managed in accordance with the privacy provisions in the Act. If you have questions
regarding the collection of your personal information, please send your inquiry to the Office of fhe Fire Commissioner, f6 :h Floor, Commerce Place, 10155 - 102"a Street, Edmonton,
©2015 Office o f the Fire Commissioner Alberta Municipal Affairs Information Request i2 D1 5 -R-0 O8 8
Page No.00151
Fire Prevention
Inspection Report
Inspection 1 2 F
.Alberta FILE# □ □ □
Phone: Fax:
ADDRESS POSTAL CODE DATE
BUSINESS NAME PHONE
PERSON CONTACTED POSITION
OTHER 1.CELL 2. FAX 3. EMAIL

CONTACT INFO
OCC. CLASSIFICATION YEAR OF BUILDING USE NO. OF STORIES
CONSTRUCTION
BUILDING OWNER PHONE
OWNERS ADDRESS SUITEAJNIT POSTAL CODE
NOTICE TO OWNER/OCCUPANT
Yes No N/A R Yes No N/A R
1. Means of egress are unobstructed. 17. Fire Department connections appear in good
condition.
2. Exit doors are equipped with approved exit 18. Private hydrants have been inspected (semi
hardware and opens freely. annual)
Date: #Hydrants
3. All Exit and Emergency lights are visible and 19. Sprinkler system has been tested, (annual) #
illuminated. Systems
Date: Wet Dry Full Partial
4. Emergency lights work properly.(30 min) 20. The sprinkler control valve is easily accessible
5. Required fire emergency plan is posted. 21. Sprinklers are free from dirt, grease, paint, etc.
6. Required fire drills are held regularly. 22. The fire alarm system has been tested,
Date of last drill Drill # (annual) Date: Type:
#Systems
7. Openings in fire separations are protected with 23. Combustibles are stored in a safe manner.
acceptable closures or openings are repaired to
maintain fire separations.
8. Doors in fire separations are kept closed. 24. Hazardous goods are processed, handled and
used safely, (list amounts where appropriate)
9. Building/occupancy limit is posted. 25. Flammable and combustible liquids are stored,
Posted # handled and used in an approved manner (list and
/ / / amounts)
10. Key lock box has required keys. 26. Compressed gas cylinders are stored in a safe
manner.
11 . Exhaust systems appear to be free of lint and/or 27. Fuel inventory records are complete.
grease.
12. Special extinguishing system has been 28. Electrical wiring and equipment are properly
inspected.(semi-annual) used, protected, terminated and covered to
Date Types prevent arching or shorting.
13. The building is adequately provided with fire 29. The heating appliance appears to be clean and
extinguishers. in good repair.
14. Fire extinguishers are properly tagged and 30. Telephone emergency# is posted.
serviced.fannuahDate of insoection
# of Extinguishers
15. Standpipe system appears in good condition. 31. Building address is visible.
16. Standpipe hose has been tested. 32.WHMIS manual available for hazardous
Date: # Hoses: material
Unless otherwise specified, it is required that the above conditions shall be remedied in accontelWeMiflh'W WftlnteHS'bftfte'Alttelftf'Rte R
Inspection Summary:
Page 2 of 2
_________________________________ Further inspection required: □ Yes □ No__________ If Yes, date:___________________

This inspection assumes no responsibility for the facility. The owner or authorized agent shall be responsible for carrying out the provisions of the Alberta Fire
Code.. A re-inspection may be required.
Inspected by: SC O # Phone: Siqnature:
R eceived by
(Print): Siqnature: Title: Date:
HELPING TO MAKE A FIRE-SAFE COMMUNITY

Thankyou foryour cooperation
W hite - C ontact Y e llo w - F ile Pink - Follow-up

Page No.00153
Public Safety Division, M unicipal A ffairs
y ^ b e & b c ^ m 10155 -102 Street
Edmonton, Alberta, T5J 4L4
Fax: 780-415-8663
DAILY ON-CALL SITUATION REPORT
DATE (Day/Month/Year):
S U M M A R Y OF CALLS
IN C ID E N T # !
File Number:
Types of Request/Notification (Investigation, Inspection, code assistance/fatality, injury, arson, HIRF)
Municipality where incident occurred Accredited/Non-Accredited
injury/fatality/arson
A brief description of the incident(s) as you understand
Types of Request/Notification (Investigation, Inspection, code assistance/fatality, injury, arson, HIRF)
Municipality where incident occurred Accredited/Non-Accredited
injury/fatality/arson
A brief description of the incident(s) as you understand
Assigned Resources (OFC Officer/Contractor/SAR Team)
M:\PSD_OFC\143508_Strat_Sys_Sup\04 W orking Folders\01 On Call Roster\UPDATED Daily On-Call Situation Report (2013 12
30).docx
Page No.00154
•
EVERY BEDROOM NEEDS A
E3 Hear the p WORKING SMOKE ALARM.
★ where you i FIRE PREVENTION WEEK OCT. 4-10,2015
firepreventionweek.org
Spsrky isatadenurkof NFPA
FIRE PREVENTION WEEK 2015 - CHILDREN'S CONTEST

HEY KIDS! YOU COULD W IN A PRIZE
H e r e 's how you e n te r :
□ Do the activities in the Fire Safety Starts with You! Activity Booklet, at school or at home.
□ You could win a home computer package or one of five special runner-up prizes! Fill out this
entry form and return it to your teacher before October 26, 2015.
NAME OF CHILD AGE GRADE
ADDRESS
CITY/TOWN PROVINCE
POSTAL CODE PHONE
PARENT/GUARDIAN PERMISSION (MY CHILD AND I HAVE READ THE FIRE SAFETY STARTS W ITH YOUI ACTIVITY
BOOKLET AND COMPLETED ALL ACTIVITIES):
PARENT/GUARDIAN NAME: ______________________________ SIGNATURE:____________________________
□ Enter the name of your school and your teacher for a chance to win a special prize, too!
YOUR SCHOOL PHONE
YOUR TEACHER
-------------------------------------------------------------------------------------------- \
FO R CLASSROOM TE A C H E R S ONLY: Please collect the
entries from children in your classroom and mail them to
Office of the Fire Commissioner, 16th Floor, Commerce
Place, 10155-102 Street, Edmonton, AB. T5J 4L4 or scan
and email to firecomm@gov.ab.ca on or before the draw
date of November 2, 2015 sure to enter your name in the
draw. Thank you for your participation!
ATCO Electric
ATCO Gas
0 by L.6CH Printing Lid 2

Page No.00155
G overnm ent
of A lberta ■_______________________________________ _______________ Fire C a su alty Report
This personal information is being collected under the O ffic e o f th e F ire C o m m is s io n e r C O M P L E T E T H IS F O R M U S IN G T H E F IR E R E P O R T M A N U A L
authority o f th e Safety C odes A ct and will be m anaged in FO R O F F IC E U S E ON LY
compliance with the Freedom o f Information a n d Protection
1 6 th F lo o r, C o m m e rc e P la c e W h ere n e c e s s a r y c h o o s e th e a p p ro p ria te c o d e an d p la c e in
o f Privacy A ct Questions about the collection o f this 1 0 1 5 5 * 1 0 2 S tre e t s p a c e p ro vid e d . IFire Numbor
information can be directed to the O ffice o f th e Fire E d m o n to n A B T 5 J 4 L 4
Commissioner, tm a it: lirecom m@ gov.ab.ca or
Phone: 7B0-415-M81
o r F a x to 7 8 0 -4 1 5 -8 6 6 3 A s e p a ra te F ire C a s u a lt y R e p o rt m u st b e su b m itte d fo r .L I I l ____l ____
e a c h d e a th o r in ju ry th at o c c u r s .
in iiiir m A i rn n c
D A T E O F F IR E T IM E L O C A T IO N O F F IR E nrn i 'i iv ^ ir
Day M o n th Y ear F u ll A d d re s s (A p t., S tre e t, City/Town) O R S e c . T w p . R g e . M e r.
i i ____I____f____ I____
N A M E O F V IC T IM AGE SEX
Last F irs t S econd 1 = M a le
2 = F e m a le
3 = U nknow n
N ature o f C a s u a lty P ro b a b le / P o s s ib le C a u s e C la s s o f V ictim S ta tu s
□
1. D e a th
2 . M in o r In ju r y (L e s s th a n 1 d a y in h o s p ita t o r o ff w o rk )
3. L ig h t In ju r y (In h o s p ita l 1 to 2 d a y s a n d /o r o ff w o rk 1 to 1 5 d a y s )
4 . S e r io u s In ju r y (In h o s p ita l m o re th a n 3 d a y s a n d /o r o ff w o rk
□
1. S m o k e In h a la tio n
2. B um
3. P h y s ic a l In ju ry
□ 1. S e n io r C itiz e n s
(6 5 v e a rs o f a o e a n d o ld e r)
2 . A d u lts (1 8 - 6 4 y e a rs o f a g e )
□ 1 . F ir e fig h te r
2 . C iv ilia n
4 . O th e r 3 . Y o u th (1 2 - 1 7 y e a r s o f a g e )
m o re th a n 1 6 d a y s ) 4 . C h ild re n (11 y e a r s o f a g e a n d u n d e r)
C o n d itio n o f C a s u a lty Ign itio n o f C lo th in g o r O th e r F a b r ic s C a u s e o f F a ilu re to E s c a p e

1 1 - A s le e p a t tim e o f fire 31 - O u te r c lo th in g 51 - T ra p p e d b y ra p id s p re a d in g o f fire / s m o k e th r o u g h
□ 1 2 - B e d rid d e n o r o th e r p h y s ic a l h a n d ic a p
1 3 - Im p a ir m e n t b y a lc o h o l, d ru g s o r m e d ic a tio n
1 4 - A w a k e a n d n o p h y s ic a l o r m e n ta l im p a irm e n t
a t th e t im e o f fir e
□ 3 2 - S le e p w e a r
3 3 - U n d e rc lo th in g
3 4 - C o s tu m e
3 5 - B e d d in g o r b e d lin e n o r p illo w
□ v e rtic a l o p e n in g s , s ta irw a y s , e le v a to r s
5 2 - T ra p p e d b y ra p id s p re a d in g o f fire / s m o k e th r o u g h
h o r iz o n ta l o p e n in g s
5 3 - H ig h fla m e s p re a d o f c o m b u s tib le in t e r io r fin is h o f
1 5 - U n d e r r e s tr a in t o r d e te n tio n 3 6 - M a ttre s s w a lls , c e ilin g s o r flo o r s
1 6 - T o o y o u n g to r e a c t to fire e m e rg e n c y 3 7 - U p h o ls te re d fu r n itu re 5 4 - B u ild in g c o lla p s e
1 7 - M e n ta l h a n d ic a p (s e n ile ) 3 8 * R ugs 5 5 - F a llin g d e b ris
18 - L e ft u n a tte n d e d (c h ild re n ) 3 9 - Ig n itio n o f c lo th in g o r o th e r 5 6 - E x p lo s io n
19 - C o n d itio n o f c a s u a lty - u n c la s s ifie d fa b ric s - u n c la s s ifie d 5 7 - E x it b lo c k e d , lo c k e d , o r o b s tru c te d
10 - C o n d itio n o f c a s u a lty - u n k n o w n 3 0 - Ig n itio n o f c lo th in g o r o th e r 5 8 - O u td o o r fire in c lu d e s fo r e s t / b ru s h fire s
fa b ric s - n o t a p p lic a b le 5 9 - C a u s e o f fa ilu r e to e s c a p e - u n c la s s ifie d
A c tio n o f C a s u a lt y 5 0 - C a u s e o f fa ilu r e to e s c a p e - u n k n o w n
21 - In ju r e d w h ile a tte m p tin g to e s c a p e
T y p e o f F a b ric o r M aterial
n 2 2 - O v e r e x e r tio n , h e a r t a tta c k
2 3 - E n te re d o r re m a in e d f o r re s c u e p u rp o s e s
2 4 - E n te re d o r re m a in e d fo r fire fig h tin g
2 5 - E n te r e d o r re m a in e d to s a v e p e rs o n a l p ro p e rty
□
41 - C o tto n
42 * W ool
4 3 - O th e r n a tu ra l fib re
4 5 * O th e r s y n th e tic fib re
s
REM ARKS:
2 6 - L o s s o f ju d g e m e n t o r p a n ic 4 6 - M ix tu re o f fib re s
2 7 - R e c e iv e d d e la y e d w a rn in g 47 * Rubber
2 8 - D id n o t a c t 4 8 - P la s tic o r p la s tic fo a m
2 9 - A c tio n o f c a s u a lty - u n c la s s ifie d 4 9 - T y p e o f fa b ric o r m a te r ia l ig n ite d - u n c la s s ifie d
2 0 * A c tio n o f c a s u a lly * u n k n o w n 4 0 - T y p e o f fa b ric o r m a te r ia l ig n ite d - n o t a p p lic a b le
V J
Signature of Person Making Report Print Name Position of Poison Making Report
Email Phone Number SCO Number Designation Number Date of Report

OFC1242 (2012/01)

Page No.00156
Government
of Alberta ■ Fire Casualty Report
This persona! information is being collected under the Office of the Fire Commissioner C O M P L E T E T H IS FO RM U S IN G T H E F IR E R E P O R T M A N U A L
authority of the Safety Codes Act and will be managed in FOR OFFICE USE ONLY
compliance with the Freedom o f Information and Protection 16th Floor, Commerce Place W h ere n e c e s s a ry c h o o s e the a p p ro priate co d e and p la ce in
o f Privacy Act. Questions about the collection o f this 10155-102 Street s p a c e p ro vided. Fire Number
information can be directed to the Office o f the Fire Edmonton AB T5J 4L4
Commissioner. Email: firecomm@gov ab.ca or
Phone: 780-415-9481 or Fax to 780-415-8663 j 1 l . 1 1
e a ch death o r in ju ry that o c c u r s .
D A T E O F F IR E TIM E L O C A T IO N O F F IR E «|_ UWUL
Day Month Year Full Address (Apt., Street. City/Town) OR Sec. Twp, Rge, Mer.
I I ___ l___ !___ 1___ I___

NAM E O F VICTIM AGE SEX
Last First Second 1 = Male
2 = Female
3 = Unknown
Nature o f C a s u a lty P ro b a b le / P o s s ib le C a u s e C la s s of V ictim S ta tu s
□
1.
2.
3.
Death
Minor injury (Less than 1 day in hospital or off work)
Light Injury (In hospital 1 to 2 days and/or off work 1 to 15 days) □
1. Smoke Inhalation
2. Burn
3. Physical Injury
□ 1. Senior Citizens
(65 vears of aoe and older)
2. Adults (18 - 64 years of age)
□ 1. Firefighter
2. Civilian
4. Serious Injury (In hospital more than 3 days and/or off work 4. Other 3. Youth (1 2 -1 7 years of age)
more than 16 days) 4. Children (11 years of age and under)
Condition of Casualty Ignitio n of C lo th in g o r O th er F a b r ic s C a u s e of F a ilu re to E s c a p e

11 - Asleep at time of fire 31 - Outer clothing 51 - Trapped by rapid spreading of fire / smoke through
□ 12 - Bedridden or other physical handicap

13 - Impairment by alcohol, drugs or medication
14 - Awake and no physical or mental impairment
at the time of fire
□ 32 - Sleepwear
33 - Underclothing
34 - Costume
35 - Bedding or bed linen or pillow
□ vertical openings, stairways, elevators
52 - Trapped by rapid spreading of fire / smoke through
horizontal openings
53 - High flame spread of combustible interior finish of
15 - Under restraint or detention 36 - Mattress walls, ceilings or floors
16 - Too young to react to fire emergency 37 - Upholstered furniture 54 - Building collapse
17 - Mental handicap (senile) 38 - Rugs 55 - Falling debris
18 - Left unattended (children) 39 - Ignition of clothing or other 56 - Explosion
19 - Condition of casualty - unclassified fabrics - unclassified 57 - Exit blocked, locked, or obstructed
10 - Condition of casualty - unknown 30 - Ignition of clothing or other 58 - Outdoor fire includes forest / brush fires
fabrics - not applicable 59 - Cause of failure to escape - unclassified
A ctio n of C a s u a lty 50 - Cause of failure to escape - unknown
21 - Injured while attempting to escape Type of Fabric or Material
□ 22 -
23 -
24 -
25 -
Overexertion, heart attack
Entered or remained for rescue purposes
Entered or remained for firefighting
Entered or remained to save personal property
n
41 - Cotton
42 - Wool
43 - Other natural fibre
45 - Other synthetic fibre
REM A RKS:
26 - Loss of judgement or panic 46 - Mixture of fibres

27 - Received delayed warning 47 - Rubber
28 - Did notact 48 - Plastic or plastic foam
29 - Action of casualty - unclassified 49 - Type of fabric or material ignited - unclassified
20 - Action of casualty - unknown 40 - Type of fabric or material ignited - not applicable
V
Signature of Person Making Report Print Name Position of Person Making Report
Email Phone Number SCO Number Designation Number Date of Report

O F C 1 2 4 2 (2 0 1 2 /0 1 ) Alberta Municipal Affairs Information Request 2015-R-0088
Page No.00157
FO R W A R D O N E C O P Y TO :
jQ A h & r k f ij i
16th Floor, Commerce Place, 10155- 102 Street Insurance Report
Government Edmonton AB T5J 4L4 or Fax to 780-415-8663 F O R O F F IC E U S E O N L Y
Fire Number Municipal Code
This personal information is being collected under the authority of the Safety Codes Act and will be
managed in compliance with the Freedom of Information and Protection of Privacy Act. Questions about the
collection of this information can be directed to the Office of the Fire Commissioner.
Email: firecomm@gov.ab.ca or Phone: 780-415*9481.
C O M P L E T E T H IS FO R M U S IN G T H E F IR E R E P O R T M A N U A L
Day Month Year Day of Week Time Municipality Where Incident Occurred Incident Code R E P O R T (Check one)
i i | | First [ G Final
Location of Fire Incident - Full Address (Apt, Street, City/Town) OR Sec. Twp. Rge. Mer. Postal Code
[ 21 Change
Name of Occupant (Last, First, Initial) Insured Address Telephone Number
□ Yes □ No
Name of Owner (Last, First, Initial) Insured Address Telephone Number
□ Yes □ No
V E H IC L E S , A P P L IA N C E S O R O T H E R E Q U IP M E N T L IS T (if applicable)
Description of Item Make Year Model Serial Number Licence No. Prov./State
E N T E R A M O U N TS B E LO W TO T H E N E A R E S T D O LLA R
Building or Vehicle Value Building or Vehicle Loss Estimate Uninsured Loss to Building or Vehicle Building or Vehicle Claim Paid
$ $ $ $
Contents Value Contents Loss Estimate Uninsured Loss to Building or Vehicle Contents Claim Paid
s $ $ $
Total Value Total Loss Estimate Total Uninsured Loss Total Claim Paid
$ $ $ s
IF IN J U R IE S O R D E A T H S O C C U R R E D C O M P L E T E A F IR E C A S U A L T Y R E P O R T P E R S O N (S ) S T A R T IN G F IR E : (Select only one)
IN JU R IE S DEATHS Age Range Gender

F.F. M en Women Youth Children TO TAL F.F. M en Women Youth Children TO TAL One Person
43
Two or More to
G Unknown or N/A
RED NUMBERS REFER TO PAGES IN THE FIRE REPORT MANUAL
Property Class Major Occupancy Area and Level of Origin Height and Ground Floor Area
4 1 1 ! 1 36 j | 38/40 1 1 M 41 I I I I
Extent of Fire / Extent of Damage Act or Omission Source of Ignition Fuel or Energy Associated With
Source of Ignition . ,
« _______________ [ I I I 44 I I I ! 48 M i l 52 I I
Material First Ignited Form of Heat Outside Fire Protection Flame Spread Interior/
Flame Spread Vertical , ,
53 M i l 56 | 57 i 58 :
Flame Spread Horizontal/ General Construction Method of Construction Year of Construction
Smoke Spread Avenue , ,
_59_____ _____ 1 1 60 | 60 | 60 I I I I
Number of Occupants Manual Fire Protection Sprinkler Protection initial Detection
J I _________________________ 1 62 | 62 | 63 I
Fixed System Other Than Sprinklers Performance of Automatic Automatic Fire Detection System Fire Detection Devices
Extinguishing Equipment ,
63 ! 63 64 | | 64 l |
Fire Services Method Fire Control W a s the fire reported to the |— . |— .
1 1 67______________________1 1 M unicipal Fire D ep artm en t? l _ l Yes l _ l No
IN S U R A N C E IN FO R M A TIO N
Name of Claims Adjuster Name of Claims Company Name of Insurance Company
Adjuster Code f i l l Claim Number: Policy Number:

Give a B rief Description of the Fire (Attach a separate sheet if additional space is required)
Signature of Person Making Report Print Name Email Address Phone Number
Date of Report (yyyy-mm<fd)

OFC1243 (2013/03) Alberta Municipal Affairs Information Request |2pi,5-RjPP88
Page No.00158
F O R W A R D O N E C O P Y TO :
16th Floor, Commerce Place, 10155 - 102 Street Fire Report
Government Edmonton AB T5J 4L4 or Fax to 780-415-8663 F O R O F F IC E U S E O N L Y
Fire Number Municipal Code
This personal information is being collected under the authority of the Safety Codes Act and will be
managed in compliance with the Freedom of Information and Protection of Privacy Act. Questions about the
collection of this information can be directed to the Office of the Fire Commissioner.
Email: ffrecomm@gov.ab ca or Phone: 780-415-9481.
C O M P L E T E T H IS F O R M U S IN G T H E F IR E R E P O R T M A N U A L
Day Month Year Day of Week Time Municipality Where Incident Occurred Incident Code R E P O R T (Checkone 1
______ 1 1 I | First Q Final
Location of Fire Incident - Full Address (Apt, Street, City/Town) OR Sec. Twp. Rge. Mer. Postal Code
I | Change

□ Yes □ No
Name of Owner (Last, First, Initial) Insured Address Telephone Number
□ Yes Q No
V E H IC L E S , A P P L IA N C E S O R O T H E R E Q U IP M E N T L IS T (if applicable)
Description of Hem Make Year Model Serial Number Licence No. Prov./State
E N T E R A M O U N T S B E L O W TO T H E N E A R E S T D O L L A R
Building or Vehicle Value Building or Vehicle Loss Estimate Uninsured Loss to Building or Vehicle Building or Vehicle Claim Paid
$ s $ $
Contents Value Contents Loss Estimate Uninsured Loss to Building or Vehicle Contents Claim Paid
$ $ $ $
Total Value Total Loss Estimate Total Uninsured Loss Total Claim Paid
$ $ $ $
IF IN J U R IE S O R D E A T H S O C C U R R E D C O M P L E T E A F IR E C A S U A L T Y R E P O R T P E R S O N (S ) S T A R T IN G F IR E: (Selectonly ens)
IN J U R IE S DEA THS Age Range Gender
F .F . M en Women Youth Children TO TAL F.F. M en Women Youth Children TO TAL One Person
Two or More to
□ Unknown or N/A
RED NUMBERS REFER TO PAGES IN THE FIRE REPORT MANUAL
Property Class Major Occupancy Area and Level of Origin Height and Ground Floor Area
4 M i l 36 l l 38/40 I I I ! 41 I I I !
Extent of Fire / Extent of Damage Act or Omission Source of Ignition Fuel or Energy Associated With
Source of Ignition , ,
42 I t t 1 44 I I I I 48 I I I ! 52 I I
Material First Ignited Form of Heat Outside Fire Protection Flame Spread Interior/
Flame Spread Vertical , ,
53 1 1 1 1 56 | 57 | 58 I I
Flame Spread Horizontal/ General Construction Method of Construction Year of Construction
Smoke Spread Avenue , ,
59 I I 60 | 60 j 60 I I I I
Number of Occupants Manual Fire Protection Sprinkler Protection Initial Detection
61 l 62 | 62 | 63 |
Fixed System Other Than Sprinklers Performance of Automatic Automatic Fire Detection System Fire Detection Devices
Extinguishing Equipment .
63 | 63 : 64 | | 64 | |
Fire Services Transmission of Alarm Response Time Action Taken
65 I ! 66 | 66 l I I I 66 |
Method Fire Control Mutual Aid Temperature Time of Alarm Time Arrived at Fire
67 | | 68 | 69 |
Officer in Charge (Name, Position, Assignment) Fire Department Incident Number Fire Department Location
IN S U R A N C E IN F O R M A T IO N
Name of Claims Adjuster Name of Claims Company Name of Insurance Company
Adjuster Code I Claim Number: Policy Number:

Give a Brief Description o f the Fire (Attach a separate sheet if additional space is required)
SCO Number Designation Number Dale of Report tyj

OFC1244 (2013/03) ' Alberta Municipal Affairs Information Reques 68
Page' No.00159
Government
Of Alberta M________________________________ Smoke Detector / Alarm Report
This personal information is being collected under the authority o f the Safety Codes Act and will be managed in compliance with the Freedom of
Information and Protection of Privacy Act. Questions about the collection of this information can be directed to the Office of the Fire Commissioner.
Email: firecomm@gov.ab.ca or Phone: 780-415-9481.
F O R W A R D O N E C O P Y TO : F O R O F F IC E U S E O N L Y
Office of the Fire Commissioner A S m o k e D etecto r / A larm R e p o rt m ust
be su b m itted with the Fire R e p o rt fo r Fire Number
16th Floor, Commerce Place
10155-102 Street resid e n tia l or in stitu tio n al p rop erty fires.
Edmonton AB T5J 4L4
or Fax to 780-415-8663
D A T E O F F IR E ____________ TIM E M U N IC IP A L IT Y W H E R E IN C ID E N T O C C U R R E D M U N IC IP A L C O D E
Day Month Year
L O C A T IO N O F F IR E IN C ID E N T - Full Address (Apt, Street, City/Town) OR Sec. Twp. Rge, Mer.
NAM E O F O W N E R / O C C U P A N T
M A N U FA C TU R E R O F D E T E C T O R O R A LA RM M O D E L N U M B ER
T Y P E O F SM O KE D E T E C T O R .Ionization 2. Photoelectric 3. Combination 4. Other 5. Unknown 6. Not Applicable
P O W E R S O U R C E O F S M O K E A L A R M D E V IC E |____ 11. Hardwired 2. Battery 3. Unknown 4. Not Applicable
P E R F O R M A N C E O F S M O K E A L A R M D E V IC E
00 No smoke alarm 07 Alarm in room of origin - not activated - mechanical failure

01 Alarm in room of origin - activated 08 Alarm not in room of origin - not activated - battery dead
02 Alarm not in room of origin - activated 09 Alarm not in room of origin - not activated - no battery
03 Alarm in room of origin - not activated - non-suitable location 10 Alarm not in room of origin - not activated
04 Alarm in room of origin - not activated - battery dead - AC not connected/disabled
05 Alarm in room of origin - not activated ■no battery 11 Alarm not in room of origin - not activated - mechanical failure
06 Alarm in room of origin - not activated 12 Not enough smoke to activate smoke alarm
- AC not connected/disabled 99 Smoke alarm activation - unknown
IM P A C T O F S M O K E A L A R M A C T IV A T IO N O C C U P A N T S IN D W E L L IN G U N IT A T TIM E O F F IR E
ON O C C U P A N T R E S P O N S E / E V A C U A T IO N
00 Not applicable/no occupants

01 Occupants evacuated safely Senior Citizens (65 Years of Age and Older)
02 Occupants did not evacuate - alarm inaudible
03 Occupants did not evacuate - physically/mentally challenged _______ Adults (1 8 -6 4 Years)
04 Occupants did not evacuate - age related (Infants/Aged)
_______ Youth (12 - 17 Years)
05 Occupants did not evacuate - unnecessary to evacuate
06 Occupants did not evacuate - suspected influence of Children (11 and Under)
drugs/alcohol
99 Occupant response/evacuation - unknown
(r e m a r k s
k,____________________________________________________________________________________________________________ 7
OFC1245 (2012/01)

Page No.00160
Government
Of Alberta ■_______________________________ Occupant Report
This persona! information is being collected under the

FORW ARD ONE CO PY TO: F O R O F F IC E U S E O N L Y
authority o f the Safety Codes Act and will be managed in
compliance with the Freedom of Information and Protection of Office o f the Fire Com m issioner
Privacy Act. Questions about the collection o f this information 16th Floor, Com m erce Place Fire Num ber M unicipal Code
can be directed to the Office o f the Fire Commissioner.
Email firecomm@gov.ab.ca or Phone: 760-415-9481. 1 0 1 5 5 - 102 Street 1 1 1 1 1 i 1 i 1 1
Edm onton AB T5J 4L4
o r Fax to 780-415-8663
C O M P L E T E T H IS F O R M U S IN G T H E F IR E R E P O R T M A N U A L
Day Month Year Day o f the W eek Tim e Municipality W here Incident O ccurred R E P O R T (Check one)
1 1 □ First □ Final
Location o f Fire Incident - Full Address (Apt., Street, City/Town) OR Sec. Twp. Rge. Mer. Postal Code
Q Change

I | Yes Q No
Name of O wner (Last, First, Initial) Insured Address Telephone Number
I | Yes Q No
EN TER A M O U N TS B E LO W TO TH E N E A R E S T D O LLA R
Contents Value Contents Loss Estimate Uninsured Loss of Contents C ontents Claim Paid
IN S U R A N C E IN F O R M A T IO N
Nam e o f Claim s Adjuster Nam e o f C laim s C om pany Nam e o f Insurance Company
Adjuster Code Claim Number: Policy Number:
SCO Number Designation Number Date (y y y y -m m -d d )
OFC1295 {2012/01)
Page No.00161
Government____________Alberta Emergency Services Medal Nomination
The personal information on this form is being collected to administer nominations for the Alberta Emergency Services Medal and its collection is authorized
under section 33(c) of the Freedom o f Information and Protection o f Privacy (FO IP) Act. All personal information collected will be managed in accordance
with the privacy provisions of the F O IP Act. If you have any questions regarding the collection of this personal information, please contact the Office of the
Fire Commissioner located at 16th floor Commerce Place, 10155 - 102nd Street, Edmonton, AB T5J 4L4. Tel: 1-866-421-6929 Fax: 780-415-8663
Email: Firecomm@gov.ab.ca
A. Recipient
Surname Given Names Gender Rank
Home Address City Postal Code Your MLA Representative (if known)
Discipline (please check all that apply to candidate's history)
| | Fire Q EM S Q Police Q Dispatch Q Fire □ EM S □ Police Q Em ergency M anagem ent
| | G overnm ent of Alberta | 1Search and R escue | | O ther (describe):
S e rv ic e F ro m S e rv ic e T o
D e p a rtm e n t P o s itio n
M o n th - Y e a r M o n th - Y e a r
B. Administrator Endorsement
Surname First Name/lnitials Position
Municipality Mailing Address Telephone Number
| | I certify that the person named in part "A" has served the organization(s) listed for the period(s) of time stated
and in every way is deserving of the Alberta Emergency Services Medal.
_______
Date (yyyy-mm-dd)
x_______________ Administrator's Signature
Please attach a letter of confirmation from each Municipality listed under Department in Section "A".
C. Awards Committee Approval (For Internal Use)
Surname First Name/lnitials Municipality Address
Position Telephone Number Recommendation
_______
Date (yyyy-mm-dd)
x__________ Signature
Please send completed form to: Office of the Fire Commissioner

Public Safety Division / Alberta Municipal Affairs
10155-102 Street
Fax: 780-415-8663
Email: Firecomm@gov.ab.ca
OFC0001 (2015/07)
Alberta Municipal Affairs Information Request m i R
o-0088
Page No.00162
ALBERTA
The A lberta Emergency

Services Medal
PRESENTED TO
IN RECOGNITION OF 12 YEARS OF LOYAL SERVICE TO

THE PEOPLE OF ALBERTA
HONOURABLE RACHEL NOTLEY

HONOURABLE DANIELLE LARIVEE
PREMIER
Page No.00163
MINISTER O F MUNICIPAL AFFAIRS

THINGS FOR THE FIRST ARRIVING OFFICER TO NOTE
The number one thing to remember is to keep yourself safe.
With drug houses and clandestine labs on the rise it is important for the member to remember
that fires in these operations are very toxic and extremely explosive. Static electricity from your
uniforms is enough to set of an explosion.
If you are first to arrive at a fire scene note the following:
■ Volume and location o f smoke.
* Color and location o f any flames.
■ Where did you first see flames, one place or more than one
■ Doors or windows open when they should be closed
■ Initial observations upon arrival, people standing around or running away.
■ Obvious things that should not be there, gas can, spout, etc.
■ DO NOT rush in, treat a fire like any other call and ensure your own safety first
■ Hazards, downed power lines, booby traps
■ DO NOT break any additional windows
■ DO NOT enter the structure

■ Take witness statements if possible
■ Contact an investigator for all fires which have ANY damages to property, injury, fatality
or suspicion o f arson.
■ Take pictures or use the dash camera.
24 hr number 1-866-618-2362
Freedam To C reate. Spirit To Achieve

Page No.00164
Report of a fire to the Office of the Fire Commissioner
Date & time o f the incident:__________________________Detachment File #:
Location o f fire:_____________________________________________________
Owner’s name, address and phone num ber:_________________•____________
Description o f property/vehicle involved:
Injuries/Fatalities sustained:
Name, address, phone number, policy number o f Insurance Company
Approximate value o f damages (best estimate):
Officer R eporting:________________________
Phone#: Fax #:
24 hr number 1-866-618-2362
Trei'do :n To -GriHtlc. Spin! To Achieve

Page No.00165
Investigation Case Management
Y N/A
□ □ File Number (POC and FERS)
□ □ Voluntary Consent to Search and/or Seizure
□ □ Safety Codes Act Warrant
□ □ Attending Fire Department Response times and actions
□ □ NFPA 921 Field Notes
□ □ Technical Reports (specify)
□ □ Photographs (CD copy)
□ □ Hazard Assessment Form
□ □ Fire Investigation Report
□ □ MAFP 1244 Fire Report
□ □ MAFP 1298 Request for Assistance
□ □ MAFP 1242 Fire Casualty Report
□ □ MAFP 1245 Smoke Alarm/Detector Report
□ □ MAFP 1295 Occupant Report
Adjudication:

Page No.00166
Court Brief
“This document is provided by the Office of the Fire

Commissioner for the purpose of the Prosecution only. Requests
from other agencies for this information should be referred to the
Office of the Fire Commissioner.”
Regina
VS
OFC Number: P09-001I
Primary Investigator:___________(Safety Codes Officer)
Offence(s): Section 67(4) (a) Safety Codes Act
Place of Offence(s):____________ , Alberta
Prosecutor:__________________
Court Location:_______________, Alberta
Submitted by:_________________(Safety Codes Officer)
Monitored by: Jacen Abrey
Date Submitted:
Next Appearance:
Date Original Disclosure Forwarded:

Page No.00167
IN THE MATTER OF THE CRIMINAL CODE, SECTION 657.3
DECLARATION OF EXPERT WITNESS
I, Michael SHYKORA. of the Office of the Fire Commissioner, in the Province o f Alberta, occupation Fire
Investigator, solemnly declare that:
1. The report annexed hereto and marked Exhibit "A" to this declaration is truthfully made
by me to the best of my knowledge and ability.
2. The curriculum vitae annexed hereto and marked Exhibit "B" is a true and accurate
summary of my training and experience.
3. 1make 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.
DECLARED BEFORE ME at )
.)
In the Province of .)
)_________________________________ signed
This_________ day of J
)
A.D. 20 . )
Commissioner for Oaths (Peace Officer)
Printed name of Commissioner (Peace Officer)

Page No.00168
D a te :_____________________ File:___________________
Address:_____________________________ Investigator:
Hazard Y /N Type Control

Natural Gas
Electrical
Power Lines
Vapours
Dusts
Gases
Liquids
Structural integrity
Confined Spaces
Ventilation
Falls
Sharp Objects
Explosives
Entrapment
Rekindle
Communications
Others on Site
Machinery
Heights
Biological Hazards
Fungus/Molds
H um an/Anim al Feces
Lighting
Animals
Limited Access/Egress
Overhead Hazards
Hazardous Materials
Access to First Aid
------ -----------------Alberta Municipal Affairs Information- Request 2015-
Page No.00169
OFFICE OF THE FIRE COMMISSIONER OFC-013-12
OPERATIONS POLICY (Hazard Assessment Form)
Effective Date
The policy comes into effect o n ______________
1. Policy Statement
Prior to starting the fire investigation the fire investigator will complete the
Hazard Assessment Form as required by the Alberta Occupational Heath and
Safety Code. The fire investigator will ensure all controls are in place as identified
on the form.
2. Application of Policy
• This policy applies to OFC Operations personnel.
• This policy applies to fire investigation contractors.
3. Policy Requirements
Operations
3.1 The fire investigator is to complete the entire hazard assessment form .
3.2 Hazards identified are required to have controls in place before the fire
investigation begins.
3.3 Any other individuals involved with the investigation are to be made
aware of the hazard assessment and controls that are in place.
3.4 The hazard assessment is to be repeated at practicable intervals.
3.5 The completed hazard assessment form shall be in the fire
investigation file.
3.6 Appendix "L" - Hazard Assessment Form

Page No.00170
360 Provincial Building-200, 5th ave South
Lethbridge, Alberta T1J 4C7
Phone: (403) 381-5483
Toll free, a fte r-h o u rs Em e rge n cy Num ber: 1 -8 6 6 -6 1 8 -2 3 6 2
Fax: (403) 382-4426
Emai!: jacen.abrey@gov.ab.ca
F ile#
Date
RE: Fire Incident:
Date of Loss:
The Office of the Fire Commissioner (OFC) was asked to assist at a fire scene in the name of municipality to
investigate the circumstances surrounding the fire that occurred on date. This document serves as a summary
of the findings of this investigation.
INVESTIGATION REPORT
SYNOPSIS
This is where you put as brief overview o f the incident
DETAILS OF THE INVESTIGATION
This section is where you detail the who, what, where, when and how you conducted the investigation
Probable Weather Conditions at the Fire Origin
Environment Canada website can provide historical weather as well Dan Kulak
Fuels and Topography
Fuel loads, inside a structure or for wildland the fuels and lay of the land
Origin Determination
This is where you comment on where and how you have come to the origin
Determination of Specific Fire Cause
This is where you eliminate to test your hypostasis
_ ^ ‘ ' 1
Government n
of Alberta ■
il Affairs Information Request 2015-R-0088
Page No.00171
Phone: (403) 381-S483
Toll free, afte r-h o u rs E m e rge n cy Num ber: 1 -8 6 6 -6 1 8 -2 3 6 2
Fax: (403) 382-4426
Email: jacen.abrey@gov.ab.ca
The following section examines the standard cause categories and explains how the final determination o f cause
was arrived at.
Railroad:
Lightning:
Equipment use:
Children.
Fireworks.
Smoking: Exhaust: Debris Bum:
Incendiary;
Miscellaneous: There is a wide range of causes to consider under miscellaneous (Cutting, grinding or welding)
Power lines:
Campfire (Fire pit):
Conclusion
This is a summary of your findings
Closure:
This report has been prepared based on the review o f the incident and acquired infonnation. It has been
prepared in a manner consistent with sound fire investigation knowledge, principles and judgement. This report
and investigation followed established guidelines, recommendations, and scientific methods, for a safe and
systematic approach as identified in NFPA 921 (Guide for Fire and Explosion Investigations). The Office o f the
Fire Commissioner requests the opportunity to re-evaluate the options contained in this report should new
infonnation arise.
If you have any questions or concerns regarding this report, please contact me at your convenience.
Sincerely,
Government n
of Alberta ■ ^ / < C [P S T C A J ]
Page No.00172
360 Provincial Building-200, S**1ave South
Phone: (403) 381-5483
Toll free, a fte r-h o u rs Em e rge n cy Num ber: 1 -8 6 6 -6 1 8 -2 3 6 2
Fax: (403) 382-4426
Jacen Abrey
Government n
of Afberta ■
Page No.00173
Phone: (403) 381-5483
Toll free, afte r-h o u rs E m e rge n cy Num ber: 1 -8 6 6 -6 1 8 -2 3 6 2
Fax: (403) 382-4426
Appendix "A"
F ile#
bf°XmeSa-
Page No.00174
Name File Number
Insurance Information
Company
Name Address Phone Number
Policy Number Effective Date Expiration Date
Policy Number Effective Date Expiration Date
Coverage
Structure/Vehicle Contents, Personal Property Other Coverage
Name of Insured Address of Insured

□ New □ Renewal
Name of Insured: Address of Insured
□ New D Renewal
Previous Insurance Carrier Address Phone Number
Previous Losses/Cancellations
Insurance Agent
Adjuster/Investigator
Adjuster Company/Name Address Phone Number
Adjuster/Investigator
Address Phone Number
Name/Company
Total Paid Loss

Structure Contents/Personal Prop Other (explain)
Structure Contents/Personal Prop Other (explain)

Page No.00175
ELECTRICAL PANEL DOCUMENTATION
Service Location Date File#
Panel Location Main Size Fuses □

Breaker O
# Rating Labeled Status # Rating Labeled Status
Amps Circuit Amps Circuit
1 2
3 4
5 6
7 8
9 10
11 12
13 14
15 16
17 18
19 20
21 22
23 24
25 26
27 28
29 30
Notes Notes
Documented by

Page No.00176
Sketches Department File#
Identification
Name Date Time

Page No.00177
Photograph Log
Date File#
Camera Photographer
Lens
Number Description Location
Initials

Page No.00178
WILDFIRE NOTES
Agency File Number
PROPERTY DESCRIPTION
Fire Damage Other Properties Involved

□ Less than one Acre of Acres
Security Comments
D Open Q Fenced Q Locked Gate
FIRE SPREAD FACTORS

Type Fire Factors: Comments
□ Ground □ Wind
□ Crown □ Terrain
AREA OF ORIGIN
PEOPLE IN AREA
At time of Fire Comments
□ YesQ No □ Undetermined
IGNITION SEQUENCE
Heat of Ignition
Material Ignited
Ignition Factor
If Equipment Make Model Serial Number

Involved
Comments:

Page No.00179
Page No.00180
FIRE INCIDENT FIELD NOTES
Agency File#
TYPE OF OCCUPANCY
Location/Address
Property Structure Residential Commercial Vehicle Wildland Other

Description
Other Relevant
Information
WEATHER CONDITIONS
Indicate Relevant Visibility Relative GPS Elevation Lightning
Weather Humidity
Information
Temperature Wind Wind Precipitation
Direction Speed
OWNER
Name DOB
d/b/s
if applicable
Address
Telephone Home Business Cellular
OCCUPANT
Name DOB
d/b/s
if applicable
Permanent Address
Temporary Address
DISCOVERED BY
Incident Discovered Name DOB
M ______________
Fire Incident Field Notes- 2 Pages Alberta Municipal Affairs Information Request 2015-R-0088
Page No.00181
Address
REPORTED BY
Incident Name DOB
Reported by
Address
INVESTIGATION INITIATION
Request Date and Time Date of Request Time of Request
Investigation Requested Agency Name Contact person/Telephone Number

By
Request Received by Agency Name Contact person/Telephone Number
SCENE INFORMATION
Arrival Information Date Time Comments
Scene Secured Yes No Securing Agency Manner of

Security
Authority to Enter Fatality Inquiry Consent Warrant

Written Verbal Admin Crim Other
□ □ □ □ □
Departure Date Time Comments
Information
OTHER AGENCIES INVOLVED

Primary Fire Department or Incident Number Contact Person/Phone
Department Agency Name
Secondary Fire
Department
Law Enforcement
Private Investigators
ADDITIONAL REMARKS
Fire Incident Field Notes- 2 Pages Alberta Municipal Affairs Information Request 2015-R-0088
Page No.00182
Event Log
Date Time Remarks

Page No.00183
INCIDENT INVESTIGATION FIELD NOTES
Name: File Number:
Location:
Master Form Completed □ N/A □ Remarks

Structure Rres Completed □ N/A □ Remarks
Vehicle Fires Completed □ N/A □ Remarks
Wildland Fires Completed □ N/A □ Remarks
Casualty Fires Completed □ N/A □ Remarks
Witness Statements Completed □ N/A □ Remarks
Physical Evidence Completed □ N/A □ Remarks
Photo Log (3 pages) Completed □ N/A □ Remarks
Sketches Completed □ N/A □ Remarks
Electrical Panel Completed □ N/A □ Remarks
Insurance Information Completed □ N/A □ Remarks
DATE ACTIVITY

Page No.00184
Voluntary Consent to
Search and/or Seizure
Date of Search and/or Seizure Location Search and/or Seizure is to take place
Pursuant to Section 8 of The Canadian Charter o f Rights and Freedoms,

Part I o f the Constitution Act, 1982, being Schedule B to the Canada Act 1982 (U.K.), 1982, c. 1 1:
Everyone has the right to he secure against unreasonable search or seizure.

The purpose of this section is to protect individuals from unjustified state intrusions upon their privacy.
In order to search an individual’s person, premises, or private dwelling place, the search must be authorized either through
the individual’s consent or by a search warrant. An individual can refuse or revoke consent at any time.
I,____________________________ , having been informed of my constitutional right as shown above,

authorize_______________________________ , a Safety Codes Officer in the fire discipline acting on behalf of the
Office of the Fire Commissioner, or his designate(s) to conduct a complete search of my premises at the address
shown above.
I am aware that the search is being conducted to determine the cause and origin of the fire, explosion or other
incident so as to protect life and property from further damage, and to fulfill the obligation under section 8 (2) of the
Administrative Items Regulation, Alta. Reg.16/2004, which reads:
“A safety codes officer for the fire discipline must investigate the cause, origin and circumstances of
every fire within the safety codes officer’s jurisdiction in which a person dies or suffers injury that
requires professional medical attention or in which property is damaged or destroyed. ”
I allow the above named Safety Codes Officer or their designate to take and use photographs, video tape
recordings, gas monitoring readings, digital images or any other means to record the scene.
I authorize and permit the above named Safety Codes Officer or their designate to remove from my premises or
private dwelling any item, object, or physical substance for the purpose related to the safety and protection of
persons or property, or in determining the cause and origin of this fire, explosion or other incident.
I am aware that in the event the investigation becomes a criminal matter, ail material, documentation, and exhibits
may be turned over to the appropriate police agency with jurisdiction.
I am aware that the above named Safety Codes Officer or their designate will be on the premises for a period of
time. I have no objection to their entering and remaining on the premises or private dwelling until completion of
their physical examination, which will not exceed__hours.
This written consent is being given voluntarily and without threats or promises of any kind. I realize that I may
revoke this consent at any time.
I acknowledge that I can refuse to give consent to a search and/or seizure and that I am waiving that right by
signing this consent form.
Signature of Person Consenting to Search/Seizure Signature of Witness
Print Name Print Name
Mailing Address Street Signature of Witness
City/TownA/illage_____ Province_______Postal Code ___________________Print Name
This personal information is being collected under die authority of the Safety Codes Act and will be managed in compliance with the Freedom of Information
and Protection of Privacy Act. Questions about the collection of this information can be directed to the Office of the Fire Commissioner, 16* Floor Commerce
Place, 10155-102 Street, Edmonton. AB. T5J 4L4. (780) 427-2732
Page No.00185
Double-click HERE to start
Government in f o r m a t io n
Of Alberta ■ To Obtain a Warrant to Enter a Private Dwelling
Municipal Affairs Place to Conduct a Fire Investigation
Sections 34(2)(b) and 48{2){a) Safety Codes Act
Canada
Province of Alberta,
Ju d icial District of
This is the information o f , o f , Alberta, hereinafter called the informant.
THE INFORMANT SAYS THAT:
1. The of is an accredited pursuant to the provisions of the Safety Codes Act and is thereby authorized to
enforce and administer the Safety Codes Act and all regulations and codes in force thereunder, including the
Alberta Fire Code (2006).
2. I am a Safety Codes Officer employed by the Municipality as a Fire Investigator and have been so
employed for years. My duties as a Fire Investigator require me to investigate fires to determine the
cause, origin and circumstances and to make recommendations as to safety.
3. On the day o f , , there was a fire on the property located a t ,, Alberta on which there is a private dwelling
place apparently in use as a dwelling (the dwelling).
4. The fire resulted in damage to the property.
5. On the day o f , , consent to enter the dwelling, to investigate the fire to determine the cause and circumstances,
was refused by the occupant of the property whose name is .
OR
5. There is currently no one present at the property to provide consent to enter the dwelling to investigate the fire
to determine the cause and circumstances. Efforts to contact the owner of the property as listed in the records
of the Municipality in person or by telephone have been unsuccessful.
6. I believe it is necessary to enter the dwelling in order to carry out an investigation of the fire to determine the
cause and circumstances and to make recommendations as to safety.
7. It is critical to obtain entry to a dwelling as soon as possible after a fire to determine the cause and
circumstances as evidence relevant to that determination may disappear or be lost.
8. i believe it will take up to hours to complete the investigation of the fire.
9. I believe it would be of assistance to the investigation to be accompanied by the following persons:

(a) a locksmith to obtain entry to the dwelling, if required;
(b) a police officer to obtain entry to the dwelling, if required;
(c) up to Safety Codes Officer(s) employed by the Municipality as Fire Investigators, if required; and
(d) up to other individual(s) with expertise in electrical, plumbing, gas, structural or other related issues,
if required.
10. Section 34 of the Safety Codes Act reads, in part, as follows:

34(2) For the purpose of ensuring that this Act and any thing issued under this Act are complied with, a
safety codes officer may, at any reasonable time and on reasonable notice, enter a private dwelling-place
MAFP 1336 (2006/01)

Alberta Municipal Affairs Information Request 2o1lS-fR-0088
Page No.00186
that is in use as a dwelling in which the officer has reason to believe there is something to which this Act
applies and, using reasonable care, may carry out an inspection . . .
(a) with the consent of the owner or occupant, or
(b) with a warrant from a justice.
34(4) In carrying out an inspection, review, examination or evaluation under this Act, a safety codes officer
may:
(a) be accompanied by any person or thing that the safety codes officer considers
would be of assistance.
11. Pursuant to s. 34(8) of the Safety Codes Act, I may be required to remove from the premises any item or
physical substance for any purpose related to the safety and protection of persons or property or in
determining the cause and origin of this fire.
12. Section 48(1) of the Safety Codes Act provides as follows:

48(1) A safety codes officer may investigate an unsafe condition, accident or fire to determine its cause
and circumstances and make recommendations related to safety.
13. Section 48(2) of the Safety Codes Act extends the provisions of section 34 to fire investigations under
section 48(1).
Wherefore the Informant prays that a warrant to enter the dwelling pursuant to section 34 of the Safety Codes Act
may be granted in order to carry out an investigation of the fire pursuant to section 48 of the Safety Codes Act to
determine the cause and circumstances and to make recommendations as to safety.
Sworn before me this day of,,

at the of in the Province of Alberta. Signature of Informant
Name of Informant (PRINT)
Signature of a Justice of the Peace

in and for the Province of Alberta
MAFP 1336 (2006/01)

Alberta Municipal Affairs Information Request Ô1?- fS oO88
Page No.OO187
Government WARRANT
of Alberta ■ To Enter a Private Dwelling Place
Municipal Affairs to Conduct a Fire Investigation
Sections 34(2)(b) and 48(2)(a) Safety Codes Act
Canada
Province of Alberta,
Judicial District of
To the Safety Codes Officer employed by the in the Province of Alberta.
This warrant is issued in respect of a private dwelling place located a t , , Alberta {“the dwelling”).
Whereas it appears on the oath of there are reasonable grounds to believe:
(a) it is necessary to enter the dwelling to investigate a fire to determine the cause and circumstances and
to make recommendations as to safety; and
(b) it is not possible to locate the owner or occupant of the dwelling to seek consent, or the occupant of the
dwelling will not consent to the investigation.
This warrant is issued to authorize you:
1. To enter the dwelling between the hours of on the day o f, and on the day o f, for the purpose of
investigating the fire to determine its cause and circumstances and to make recommendations as to safety;
and
2. To be accompanied by:
(a) a locksmith to obtain entry to the dwelling, if required;
(b) a police officer to obtain entry to the dwelling, if required;
(c) up to Safety Codes Officer(s) employed by the Municipality as Fire Investigators, if required; and
(d) up to other individual(s) with expertise in electrical, plumbing, gas, structural or other related issues,
if required.
Dated this ______ day of , at , Alberta.
Signature of a Justice of the Peace

in and for the Province of Alberta
MAFP 1336 (2006/01) Alberta Municipal Affairs Information Request?2jQ1§-R-0OSS

Page No.OOISS
WITNESS STATEMENT Department File#
Identification
Name Date Time
Statement

Page No.00189
WITNESS STATEMENT Department File #
Identification
Name Date Time
Statem ent

Page No.00190
WITNESS STATEMENT Department F ile #
Identification
Name Date Time
Statem ent

Page No.00191
CASUALTY FIELD NOTES
Agency Incident Date File Number
DESCRIPTION
Name DOB Sex/Race
Address Phone #
Other Identifiers______________
Description of Clothing and Jewelry
Smoker □ Yes □ No □ Unknown
CASUALTY TREATMENT
Treatment at Scene □ Yes □ No By
Transported to Remarks
SEVERITY OF INJURY_______
D Minor □ Moderate □ Severe Fatal
Describe Injury
NEXT OF KIN
Name Address Phone #
Relationship Notified on By
FATALITY INFORMATION
Where was victim initially found?
Who located victim?___________
Body Position when initially found?
Victim's Appearance
Body removed by To
Photographed in place Significant blood present under/near victim
□Yes D N o □Y es Q N o
MEDICAL EXAMINER/CORONER
Agency
Date of Examination Location
Autopsy Required Autopsy Completed Copy Attached
□Yes Q N o □Yes O No Q fe s D N o
Full body x-rays QYes ^ N o Other x-rays

Page No.00192
|_ j Physical |_ | Dental |_ | Fingerprints Q Prior Injury
Identification Appearance Records Comparison
made from _| Other
Condition of Trachea:
Evidence of Pre-Fire Injury Type/Location
□Y es D N o
Blood Samples Taken Other Specimens collected
□Y es O k t
CO Level Blood Alcohol Other
Cause of Death
REMARKS

Page No.00193
STRUCTURE FIRE
Agency File#
TYPE OF OCCUPANCY
LJ Residential □ Single Family □ Multifamily □ Commercial □ Governmental
□ Church □ School U Other
PROPERTY STATUS
Occupied at time of Fire Unoccupied at time of Fire Vacant at time of Fire
□ yes D no □ YES □ no □ yes □ NO
Name of Person last in Time and date in structure Exited via which door/egress
structure prior to fire
Remarks
BUILDING CONSTRUCTION
Foundation Basement Crawl Space Slab Other
Type
Material Masonry Concrete Stone Other
Exterior Wood Brick/Stone Vinyl Asphalt Metal Concrete Other

Covering
Roof Asphalt Wood Tile Metal Other
Type of Wood Balloon Heavy Ordinary Rre Non- Other

Construction Frame Timber Resistive Combustible
ALARM/PROTECTION/SECUR1TY
Sprinklers Standpipe Security Camera(s)
□ YES □ no □ YES □ NO □ YES □ NO
Smoke Detectors/Alarms Hardwired Battery
□ YES □ NO □ YES □ NO □ YES □ NO
Were Batteries in place Location(s):
□ YES □ NO
Hidden Keys Security Bar Windows
ED YES EH NO Where: □ yes D no
Doors
□ yes O no

Page No.00194
REMARKS
CONDITION OF DOORS/WINDOW'S
Locked Unlocked but closed Open
Doors
Forced entry Who forced (if known)
n
YES □ NO
Windows Secure Unlocked but Open Broken
dosed
Broken by First Responders Remarks

□ yes □ NO
FIRE DEPARTMENT OBSERVATIONS

Name of first on scene: Department:
General observations:
Obstacles to extinguishment: First-In Report Attached?

□ YES □ NO
UTILITIES
on D o ff none Overhead □ Underground
Electric
Company: Contact: Telephone:
□ ON □ OFF □ NONE Natural |_| LPG U Oil

Gas/Fuel
Company: Contact: Telephone:
Water Company: Contact: Telephone:
Telephone Company: Contact: Telephone:
Other Company: Contact: Telephone:
COMMENTS

Page No.00195
VEHICLE INSPECTION FIELD NOTES
File# Date of Occurrence
Insured Date of Assignment
Address (City, Province)
Loss Location Date of Inspection
Inspection Location
Stolen? □ Yes □ No Time of Inspection

Recovered by:
Police Report Fire Report
□ # of Keys Alarm System □ Yes No
Hidden Key □ Yes No Location
VEHICLE
Make Model Year
VIN Odometer
EXTERIOR
Tires Tire Type Wheel Tire Tread Lugs Missing
Type Depth
LF
LR
RR
RF
SP
Doors Glass Y/N Window Locked Open/Closed Prior Damage

Up/ Down Y/N
LF
LR
RR
RF
Body Panels Construction Condition Prior Damage

F Bumper
Grill
LF Fender
LR Quarter
R Bumper
RR Quarter
RF Fender
Hood

Page No.00196
Roof
Trunk
Under Hood Intact Missing Parts Missing Condition

Engine
Battery
Belts/Hoses
Wiring
Accessories
FLUIDS Level Condition Sample Taken

Oil
Transmission
Radiator
Pwr Steer
Brake
Clutch
INTERIOR Intact Missing Parts Missing Condition

Dash Pod
Glove Box
Strg. Column
Ignition
Front Seat
Rear Seat
Rear Deck
MAKE/MODEL
Stereo
Speakers
Accessories
FLOOR SAMPLE 1fAKEN
LF
LR
RR
RL
PERSON,fU. EFFECTS IN THE INTERIOR
TRUNK OR CARGO AREA
AFTERMARKET ITEMS NOT PREVIOUSLY DESCRIBED

Page No.00197
Page No.00198
Clerk’s Stamp
COURT FILE NUMBER
court Court of Queen’s Bench of Alberta
JUDICIAL CENTRE
PLAINTIFF(S)
DEFENDANT(S)
docum ent Affidavit of Service
ADDRESS FOR SERVICE

AND CONTACT
INFORMATION OF PARTY
FILING THIS DOCUMENT
AFFIDAVIT OF [NAME OF DOCUMENT SERVER]
Sworn/Affirmed o n ___________________, 20___
I, [Name of document server], of [Name of city/town], Alberta, SWEAR/AFFIRM THAT:
1. I have personal knowledge of the following information, except where I state that it is based on
information from another person, in which case, I believe that information to be true.
2. I am 18 years of age or older.
3. On [date], I served [Name of person who received the documents], with a copy of: (Choose
those which apply)
I I the following documents, which are filed with the Court:

■ [Name of other filed document], filed [date filed with the Court],
■ [Name of other filed document], filed [date filed with the Court],
I I the following documents, which are not filed with the Court:
■ [Name of other document, not filed], which is attached and marked as Exhibit “ ”
to this Affidavit,
■ [Name of other document, not filed], which is attached and marked as Exhibit “ ”
to this Affidavit.
Generic Affidavit o f Service Alberta Municipal Affairs Information

Page No.00199
-2-
I served the document(s) listed above using the following method of service: (Choose one)
(Personal service)
HH by delivering the document(s) to and leaving them with [Name of person who received the
documents] at [Address in full, including Postal Code].
(Recorded mail)
EH by causing a copy of the document(s) to be sent by recorded mail to [Name of person who
received the documents] at [Address in full, including Postal Code]. Service was effected
on [date of delivery], as is evidenced by the acknowledgment of receipt, signed by the
individual to whom it is addressed, which is attached and marked as Exhibit ‘ ’ to this
Affidavit.
(Electronic method [for non-commencement documents only])

ED by sending an electronic (scanned) copy of the documents) to [Name of person who
received the documents] at [Electronic address (email or fax#)], which has been specified
by that party as the address to which information or data may be transmitted in respect of
the action. Service was effected on [date of delivery], as is evidenced by the confirmation
of the successfully completed transmission, which is attached and marked as Exhibit
* ’ to this Affidavit.
(As directed by the Court)

□ in accordance with the Order of the Court, dated [Date of court order], by [Provide
particulars of method of service stipulated and the date service was effected].
(Other)
ED other method of service: [Provide particulars of method of service and date service
effected].
I have the following other information regarding service of the document(s):
(a) [Add any other information relating to service].
SWORN/AFFIRMED BEFORE ME •N
on_________________________ , 2 0 ____
a t _________________________ , Alberta.
► Signature of document server
Commissioner for Oaths

in and for the Province of Alberta J

Page No.00200
Public Safety Division | Alberta Municipal Affairs
16th Floor, Commerce Place 110155-102 Street
Edmonton, Alberta T5J-4L4
Evid en ce F orm
File N umber :
Date of Incident : Storage location :
Item No . Description Location Destroyed Released
□ □
□ □
□ □
□ □
□ □
□ □
□ □
□ □
□ □
□ □
H ow W as the Evidence Received ? Date R eceived : Date Stored:
□ R emoved F rom Scene by Investigator.
□ Received by Investigator From :

N a m e , C o m pa n y , o r D e p t .
R eceived via : □ D H L/ L oomis □ P urolator □ A irborne □ M ail □ In Person

□ Freight :__________________________________
Name of C o m pa n y
□ Other : ___________________________________________________
D e s c r ib e
R e c e iv ed by C a s e F ile In v est ig a to r
Location Evidence R emoved
O w ner C o m pany
A ddress 1 A ddress 2
C ity C ity
PROVINCe P o stal C ode P hone P rovince P ostal C ode P hone
Page | 1

Page No.00201
Public Safety Division | Alberta Municipal Affairs
16lh Floor, Commerce Place 110155-102 Street
Edmonton, Alberta T5J-4L4
E vidence F orm
Internal Examination Examination by Others
D ate Da te D ate
Investigator P ulled E xamined N am e Date of Examination
R etu r n e d
C om pany
Ad d ress
C ity P r o v in c e P o stal C o d e P hone
Evidence Destruction A u th o r ize d by
In v e st ig a t o r 's A u thorization D ate

A u th o r ize d by Date
In v e st ig a t o r 's A u thorization Date
Destroyed by date N ame Date of Examination
Evidence R elease C om pany
Ad d ress
S ignatur e of P e r s o n R eceiving E vid en c e
C ity P r o vin ce P o st a l C o d e P hone

P e r s o n R eceiving E v id en c e (P r in t ) D ate
A u th o r ize d by
C o m pa n y Name
In v e st ig a t o r 's A u thorization D ate

Ad d r e s s
C ity P r o vin ce P o stal C ode
Au th o r ize d by D ate
In v est ig a t o r ' s A uthorization D ate
R el ea se d V ia
R emarks
Page | 2

Page No.00202
Government LOCAL FILE NUMBER
of Alberta ■ ELECTRICAL INCIDENT REPORT FORM DATE
Human Fatality L J Yes Human Injury □ Yes Animal Fatility □ Yes

(click one) □ No (click one) n no ( c lic k o n e ) □ No
Date o f A ccide n t T im e o f Day
Exact Location o f A ccident
LSD Section T o w ns h ip Range W est o f
D ETA ILS Nam e o f Person In ju re d o r In v o lv e d O ccupation Phone No.

Age
Address Postal Code
D escription o f In ju r y ( if a ny)
OF
E m ployer Phone No.
Address Postal Code
D escription o f A c c ide n t (s ta te fa c ts only)
A CCID EN T

Page No.00203
Double-click H ER E to start
Government Release from

of Alberta ■ Responsibility
Municipal Affairs
Date of Incident Tim e of Incident Incident Number
Nam e of Fire Department That Attended the Incident Telephone Number
Address Street City/ Town/ Village Province Postal Code
A dd re ss of Property Involved in Incident Street C ity/ Town/ Village Province Postal Code
Type of Occurrence ( c h e c k O N E o n ly )
!] Fire | Sprinkler Alarm J Fire Alarm | Service Call
J Other - s p e c if y :
The following have been suspended and/or shut down by Fire Department personnel
C h o o s e a l[ th a t a re a p p ro p ria te
J Power J Standpipe and Hose Systems

J Gas ] Sprinkler System
Water ~^\ Fire Alarm System
] CO, Smoke/Heat Detector Kitchen F/X System
Portable Extinguisher ~\ Other - s p e c if y :
The following must be completed/checked by a qualified person before the building is safe for occupancy
C h o o s e a l [ th a t a re a p p ro p ria te
J Power - Turned On J Standpipe and Hose Systems

J Gas - Turned On Sprinkler System Verification
Water - Turned On J Fire Alarm System Verification

] CO, Smoke/Heat Detector j Kitchen F/X System Verification
] Portable Extinguisher J Other - s p e c if y :
Remarks:
While the has made every effort to fully extinguish the fire at , please be advised that there exists a possibility that the fire is not
completely extinguished and may re-ignite. The owner is strongly advised to post a fire watch for a period not less than 48
hours.
Signature of Fire Officer Signature of Owner/Agent
Print Name Print Name
Business Telephone Number
T h is p e rs o n a l in fo rm a tio n is b e in g c o lle c te d u n d e r th e a u th o r ity o f th e S a fe ty Codes Act and w ill b e m a n a g e d in c o m p lia n c e w ith th e F re e d o m o f

In fo rm a tio n a n d P ro te c tio n o f P riv a c y A c t
MAFP 1337 (2004/12)

Page No.00204
Print Form 1 Reset Form ^
ia u a a a ^ u B Bi a t B a B M a a
GAS INVESTIGATION REPORT
FOR OFFICE USE ONLY

Government
Gas File Num ber 16100-G01-
This personal information is being collected under the authority o f the Sqfety Codes A ct
and w ill be managed in compliance with the Freedom o f Information and
Fire F ile Number
Protection o f Privacy Act.
REASON FOR INVESTIGATION__________________________________________________________________

[“ Fatality [“ Property Damage o f over $250 [“ Injury requiring professional medical attention |~ Carbon M onoxide Poisoning
SITE INFORMATION
Date o f investigation: Time: Municipality:
Location o f Incident - Full Address (A pt S treet Ctty/Town) OR (Sec. Twp. Rge. M er.) Postal Code
Name o f Occupant (L ast F irst Initial) Address Phone Number
Name o f Owner ( L ast F irst Initial) Address Phone Number
APPLIANCE, VEHICLE OR OTHER EQUIPMENT

Description o f item Make Year Model Serial Number Licence No. Prov_/State
INJURIES
WITNESSES
Name Address Phone number
SAFETY CODES OFFICER INFORMATION

Date o f incident Time o f incident Reported by Was installation previously inspected? Permit#
1“ Yes p No
Fire Officer in Charge Position Assignment
|~ In clu d e a b rief descrip tion o f in cid en t on separate sh eet o f paper and attach.
Photographs attached: (“ Yes [ ~ No

Gas Officer Name (Print) E-mail address Phone Number
SCO Number Date report submitted Signature .
F orw ard copy to:

Alberta M unicipal A ffairs, Plumbing and Gas Administrator
16th Floor, 10155-102 Street, Edmonton AB T5J 4L 4, Phone: 1-866-421-6929, Fax: 780-427-8686, E-mail: safety.services@ gov.ab.ca

' ' Page No.00205
/dberta Municipal Affairs Report of Product Malfunction
Related to Plumbing and Gas Equipment Design
Date:
| i______________________ _______1
A. PRODUCT INFORMATION
Type of Equipment Manufacturer
Model Number Serial Number
Equipment Ratings/Rating Plate Infomnation
B. CERTIFICATION
Certification Agency
Additional Certification Markings & Infomnation
C. OWNER OF PRODUCT
Name Telephone Number
( )
Address Street Town/City Province Postal Code Fax Number
( )
Location of Equipment (Street address, legal address and actual location In building)
D. SOURCE OF REPORT
Name of Person W ho Inspected The Product T itle /S C O Number
Name of Organization Telephone Number Fax Number

( ) ( )
Address Street Town/City Province ' Postal Code Jurisdiction
E. DESCRIPTION OF EQUIPMENT FAILURE

(Attach an extra page if more space is required.)
Send this completed form to: Alberta Municipal Affairs

Safety Services
16th Floor 10155 102 Street
EDMONTON AB T5J 4L4
Telephone: 1-866-421-6929 Fax: 780-427-8686
This information is being collected for the purposes o f investigating an unsafe condition in accordance with the Safety Codes A ct
Questions about the collection o f this information can be directed to Public Safety Division, Safety Services, 7 6 * Floor, Commerce
Place, 1 0 1 5 5 - 102 S treet Edmonton, Alberta T 5 J 4 L 4 ,1-866-421-6929.
PSD1271 (2007/09)
Page No.00206
This form is to be completed when a product or equipment failure occurs due to
design, manufacturer, or standard deficiency. This provides information that can
be used to identify repeat product failure, which will be forwarded to the
appropriate certification agency or standards body, by Alberta Municipal Affairs.
The failure may be a result of:

• the unit not being manufactured according to the standard;
• the unit failing to operate as intended;
• a component part failure for reasons other than abuse or long term
operation.
This form is not to be used for incorrect installation or application.
Product Information
Define the type of equipment, e.g. plumbing fixtures, piping, furnace, water
heater, etc. This includes specific information on rating plate, e.g. BTU Rate,
orifice size, manifold pressure, plumbing product number and standard number
stamped on material, etc.
Identify markings of certification agency certifying equipment. Include the number
appearing on the certification mark.
Owner of Product
Give the name and address of the owner of the fixture, appliance or equipment.
Also, give the street address, legal description and the location in the building of .
the equipment or appliance.
Source of Report
Give the name of the person who inspected the product in case future contact is
necessary. Ensure the jurisdiction is completed.
Description of Equipment Failure

Describe the failure of, or problem with, the equipment and the determined
cause. Include any action taken to correct the problem and state if the problem
is corrected (attach extra pages if required). Include any related installation
inspection reports.
PSD1271 (2007/03)
Page No.00207
Fire Prevention Office of the Fire
Inspection Report Commissioner
Suite 250, 7015 Macleod Trail South Inspection 1 2 F
Calgary, Alberta T2H 2K6 FILE# □ □ □
Phone: (403) 592-4219 Fax: (403) 297-4174
ADDRESS POSTAL CODE DATE
BUSINESS NAME PHONE
PERSON CONTACTED POSITION
OTHER 1. CELL 2. FAX 3. EMAIL

CONTACT INFO
OCC. CLASSIFICATION YEAR OF BUILDING USE NO. OF STORIES
CONSTRUCTION
BUILDING OWNER PHONE
OWNERS ADDRESS SUITE/UNIT POSTAL CODE
NOTICE TO OWNER/OCCUPANT
Yes Nd N/A R Yes No N/A R
1. Means of egress are unobstructed. 17. Fire Department connections appear in good
condition.
2. Exit doors are equipped with approved exit 18. Private hydrants have been inspected (semi
hardware and opens freely. annual)
Date: #Hydrants
3. All Exit and Emergency lights are visible and 19. Sprinkler system has been tested, (annual) #
illuminated. Systems
Date: Wet Drv Full Partial
4. Emergency lights work properly.(30 min) 20. The sprinkler control valve is easily accessible
5. Required fire emergency plan is posted. 21. Sprinklers are free from dirt, grease, paint, etc.
6. Required fire drills are held regularly. 22. The fire alarm system has been tested,
Date of last drill Drill # (annual) Date: Tvpe:
#Systems
7. Openings in fire separations are protected with 23, Combustibles are stored in a safe manner.
acceptable closures or openings are repaired to
maintain fire separations.
8. Doors In fire separations are kept closed. 24. Hazardous goods are processed, handled and
used safely, (list amounts where appropriate)
9. Building/occupancy limit is posted. 25. Flammable and combustible liquids are stored,
Posted # handled and used in an approved manner (list and
/ / / amounts)
10. Key lock box has required keys. 26. Compressed gas cylinders are stored in a safe
manner.
11. Exhaust systems appear to be free of lint and/or 27. Fuel inventory records are complete.
grease.
12. Special extinguishing system has been 28. Electrical wiring and equipment are properly
inspected.(semi-annual) used, protected, terminated and covered to
Date Tvoes prevent arching or shorting.
13. The building is adequately provided with fire 29. The heating appliance appears to be clean and
extinguishers. in good repair.
14. Fire extinguishers are properly tagged and 30. Telephone emergency # is posted.
serviced.(annual)Date of inspection
# of Extinquishers
15. Standpipe system appears in good condition. 31. Building address is visible.
16. Standpipe hose has been tested. 32.WHMIS manual available for hazardous
Date: # Hoses: material
AiDerra Municipal Affairs information R eques 2U15-R-UU88
Inspection Summary:
Page 2 of 2
Further inspection required: □ Yes □ No If Yes, date:

This inspection assumes no responsibility for the facility. The owner or authorized agent shall be responsible for carrying out the provisions of the Alberta Fire
Code.. A re-inspection may be required.
Inspected by: SCO# Phone: Signature:

R eceived by
(Print): Signature: Title: Date:
HELPING TO MAKE A FIRE-SAFE COMMUNITY

Thankyou foryour cooperation
W hite - Contact Y e llo w - F ile P in k -F o llo w -u p

Page No.00209
Safety Services
10155-102 Street
Edmonton, Alberta, Canada T5J 4L4
Telephone 1-866-421-6929
, , , Fax 780-427-8686
Municipal Affairs safety.servlces@gov.ab.ca
www.municipalaffairs.alberta.ca
A P P L IC A T IO N F O R R E L A X A T IO N O F R E Q U IR E D
F A C IL IT IE S F O R T H E D IS A B L E D
Sentence 2.2.1.4.(1) of Division C of the Alberta Building Code 2014 states:

The Chief Building Adm inistrator may grant relaxation of one or more of the requirements of Section 3.8. if
an owner can demonstrate to the satisfaction of the Chief Building Adm inistrator and Barrier-Free
Adm inistrator that
a) the specific requirements are unnecessary, or
b) extraordinary circumstances prevent conformance.
W e the owner/tenant (or their representative) of the building described below have been asked to provide
barrier-free facilities as indicated below in conformance with the requirements of Section 3.8. of the Alberta
Building Code and are requesting a relaxation.
P L E A S E P R IN T C L E A R L Y
Building Address ________________________________________________________________________________
Contact Name _____________________________________ Phone No. _________________________________
Name and Type of B u sine ss________________________________________________________________________

Contact Address _________________________________________________________________________________
Safety Codes Officer ________________________ M unicipal/A gency___________________________________

Ensure the above information is complete as we may need to contact you for clarification.
T Y P E O F C O N S T R U C T IO N (M a rk w ith X)
New Building Q Addition to Existing Building Q Renovation o f Existing Building I_j
CODE REQUIREMENTS REQUESTED TO BE RELAXED (Mark with X)

1. Access to the building |_ j
2. Access to and supply of washroom facilities ; :
3. Other (please specify) _______________________________________________ I
W e seek relaxation of the marked (X) items for the following reasons.
P lea se p ro v id e a d e ta ile d e x p la n a tio n fo r e ac h m a rk e d ite m o n a s e p a ra te s h e e t and a ttac h
a s m a ll s c a le flo o r p lan la y o u t, s ite plan etc. to illu s tra te th e a re a s o f c o n c e rn .
Send completed application form and payment of $105.00 ($100.00 plus $5.00 GST) to Government of
Alberta at the above address to the attention of the Chief Building Administrator.
Payment Information: GST Registration #R124072513

□ Cash □ Cheque (payable to Government of Alberta)
To pay by credit card indicate your email address below and we will send you a secure payment link
E m a il:_________________________________________ .
This information is being collected for the purpose to administer application for relaxation of required facilities for the disabled, in accordance with section
33(c) of the Freedom of Information and Protection of Privacy Act. Questions about collection of this information can be directed to Alberta Municipal
Affairs, 16,h floor, Commerce Place, 10155-102 Street, Edmonton, Alberta, T5J 4L4, 1-866-421-6929.
Alberta Municipal Arrairs inrormat
Government of Alberta ■ Safety S e rv ice s
16lh Floor, Commerce Place
Municipal Affairs 10155-102 Street
Edmonton, Alberta, Canada T5J 4L4
Telephone 1-866-421-6929
Fax 780-427-8686
safety.services@gov.ab.ca
www.municipalaffairs.alberta.ca
B u ild in g P e rm it A p p lic a tio n

O ff-S ite M a n u fa c tu re d S tru c tu re s
Manufacturer's N am e:__________________________________ Phone: __
Address: ________________________________________________________
Address: ___________________________________________ Postal Code:
Contact Person: _______________ _____
T y p e o f S tru c tu re :
□ Manufactured Homes □ Part 10 Structures
N u m b e r o f L ab e ls R e q u e s te d :
Manufactured Home _________x $3.50 each =

Part 10 Red ________ x $30.00 each =
Part 10 Green ________ x $30.00 each =
Q u a lity M a n a g e m e n t P ro g ra m :
□ CSA □ Municipal Affairs □ QAI □ Intertek

□ Other - Please sp ecify_____________
Please make cheques payable to Government of Alberta.
To pay by credit card please indicate your email address below - you will be sent an email with
a secure payment link:
Email a ddress:____________________ ______
D o n o t w rite y o u r c re d it c ard in fo rm a tio n on th is fo rm . W e are p ro h ib ite d fro m c o lle c tin g

th is in fo rm a tio n . If it is w ritte n on th e fo rm it w ill be re tu rn e d to you w ith o u t b ein g
p ro c e s s e d .

Page No.00211
Application for Authorization
To Apply for a Permit
Government
TYPE OF CERTIFICATE
B e fo re y o u r a p p lic a tio n ca n be c o m p le te d ,
y o u m u st: I I New ($40.00) O Renewal ($40.00)
Indicate below the type of Certificate you are applying for and if renewing,
a) complete the competency requirements for,
provide existing Certificate Number:
or presently hold a Private Sewage (PS),
Water and Sewer Service (R), or Restricted □ Private Sewage
Private Sewage (RPS) Certificate. Disposal Number:
Expiry Date
b) have a satisfactory work record, and
□ Water and
c) pay the fee of $40.00 for a one year period. Sewer Number:
Expiry Date
I I Restricted Private Sewage
Disposal Number: _____
Expiry Date
APPLICANT INFORMATION
Name of Applicant:
Name of Company:
Mailing Address of Company Street:
City/Town: Province: Postal Code:
Please indicate in the check box below the n i mber you would like to appear on our website:
Home Telephone: Business Telephone: Mobile Telephone:
□ □ □
I certify I have read the requirements listed above and that the information provided is true and correct.
Signature of Applicant Date
S e n d the form an d the fee to: Make cheques and money orders payable to the Government of Alberta.
if you would like to pay by credit card please indicate your email address
below - you will be sent an email with a secure payment link.
Safety Services
16,h Floor, Commerce Place Email address:
1 0 1 5 5 - 102 Street
Edmonton AB T5J 4L4
Email: safety.services@gov.ab.ca D o n o t p ro v id e y o u r c re d it c a rd in fo rm a tio n o n th is fo rm o r b y e m a il. W e

Fax: (780) 427-8686 are p ro h ib ite d fro m c o lle c t in g th is in fo rm a tio n . If the fo rm c o n ta in s c re d it
Phone: 1-866-421-6929 c a rd in fo rm a tio n it w ill be retu rne d to y o u w ith o u t b e in g p ro c e s s e d .
The personal Information is being collected under the authority of the Safety Codes Act tor the administration of the Alberta Private Sewage Disposal Regulation, and will be
managed in compliance with the Freedom o f Information and Protection of Privacy Act. If you have any questions, please contact Alberta Municipal Affairs. Safety Services,
1&* Floor. 10155 - 102 Street, Edmonton, Alberta, T5J 4L4, Telephone 1■866-421-6929.
FO R O F F IC E U S E O N LY - C A S H IE R
Account Code - 446145 Fund - 00 Org. Code - 3605 Program Code - 03215

Page No.00212
Liberia
M u n icip a l A ffa irs Sa fe ty Codes C o u n c il
Guidelines for Requesting Changes

to the Alberta Safety Codes
Suggestions for changes to the Alberta Safety Codes are welcome from anyone at any
time. The following points will help guide you in preparing your submission.
W hat are the Alberta Safety Codes?

The Alberta Safety Codes are made up of 29 separate Codes, developed by various
code and standard writing organisations from across Canada and the United States.
Each code or standard is reviewed for relevancy in Alberta by the appropriate technical
council of the Safety Codes Council, who in turn make recommendations to the Minister
of Municipal Affairs for adoption of the codes by regulation. Municipal Affairs and local
municipalities are then responsible for the proper administration of each code.
W ho Must Be Convinced
To bring about a change in one of the Alberta Safety Codes, you must convince the
appropriate technical council of the Safety Codes Council that your suggested change is
needed and that it is technically correct. These technical councils are made up of
volunteers from all regions of Alberta and many facets of industry. These volunteers
are chosen for their expertise in the area covered by their respective technical councils.
Code Change Request Requirements
Supporting Documentation
Code Change Requests should be accompanied by enough documentation to make the
case that a change is needed. This documentation can include research and testing
results, statistics, case studies and so forth.
Cost/Benefit Analysis
One important aspect to include in the documentation supporting a Code Change
Request is information on the costs of implementing it and the benefits likely to be
achieved. This is not to suggest that every Code Change Request must be
accompanied by a detailed cost/benefit analysis; however, the technical councils must
give due consideration to these questions and so they expect proponents of changes to
contribute information that will assist them in this task. Where the requested change
has major cost implications, the technical councils may ask that a detailed cost/benefit
analysis be provided.
Enforceability
Proponents of Code Change Requests should also bear in mind that there is little use in
requesting Code provisions for which there are no practical means of enforcement.
This problem can arise when requested changes are written in such language that there
are no existing tools or models that can be used to evaluate whether or not a design or
construction actually conforms to the provision.
A related issue is the implications of Code Change Requests for the existing code
enforcement infrastructure. Enforcement agencies such as municipal departments and
fire services have finite resources, so requesting changes that would cal! for substantial
- 1- Page No.00213
/dlberfa
M u n icip a l A ffa irs Sa f e ty Codes C o u n c il
increases in enforcement resources would require very strong justification to be

favourably received by the technical councils.
Therefore, a Code Change Request should include information on enforcement
implications, including available resources.
Clarity
The technical councils also expect proponents to make very clear what specific change
they would like to see. Code Change Requests should identify the shortcomings of the
existing requirement, and existing Code provisions that would be affected by the
change. New wording should be suggested to address these shortcomings. It is
recognized that not all those interested in improving the Codes can be experts in Code
writing, and so Alberta Municipal Affairs staff will suggest improvements to the proposed
wording, if necessary. Nevertheless, if specific wording is used, it will help to make the
proponent’s intentions clear. Code Change Requests that lack clarity may be returned
to the proponents for clarification, thus prolonging the time required for the technical
councils to deal with the requests.
Code Development Process

Persons with an active interest in the contents of the Alberta Safety Codes should
maintain an awareness of the various stages of the Code cycle.
Submission
Although suggestions for changes to the Alberta Safety Codes are welcome from
anyone at any time, the Codes are revised and published according to a schedule and
there may be a delay between the submission of a Code Change Request and its
publication in the relevant Code, even after the request has passed through the
technical councils and public review processes. Code Change Requests submitted
immediately before or after a public review are generally deferred to the next code
cycle.
Provincial Review
When a Code Change Request is received by Alberta Municipal Affairs, staff reviews it
for completeness and to determine whether it meets the submission criteria. If it does
not meet submission criteria, MA&H staff may contact the proponent for more
information or clarification, or they may reject the Code Change Request altogether, if it
meets the submission criteria, it will be forwarded to the appropriate technical council of
the Safety Codes Council for review.
The first step in the review is to determine whether or not the Code Change Request
pertains to an Alberta-specific requirement or to a requirement in one of the base code
documents, on which the Alberta Safety Codes are based. If it is determined that the
Code Change Request pertains to a requirement in one of the base code documents,
the request will be returned to the proponent with instructions to direct their request to
the appropriate code or standard-writing organisation identified at the end of these
guidelines.
If it is determined that the request pertains to an Alberta-specific requirement, at that
point it may be accepted as a request and put forward for public review as a Code
Change Proposal, it may be modified prior to submission for public review, or it may be
" " " Page No.00214
Liberia
Municipal Affairs Sa f e t y Codes Co u n c il
rejected as being inappropriate or unnecessary. Regardless of the outcome, once a

decision has been made, the technical council will notify proponents of the status of
their Code Change Request.
Public Review
If the technical councils determine that the Code Change Request is appropriate, it will
then be included as a Code Change Proposal in a public review that is held at least
once every code cycle. Code users include architects, engineers, local code
enforcement authorities as well as the general public. Code users are asked to
comment on the feasibility, enforceability, cost effectiveness and policy implications of
each Code Change Proposal. Code users are asked to verify that a proposed change
establishes the minimum acceptable provision, given the risks to buildings addressed by
that provision.
Disposition
At the end of the public review, the comments on each Code Change Proposal are
compiled and reviewed by staff at Alberta Municipal Affairs. Based on the comments
and recommendations from code users, MA&H staff will make recommendations to the
appropriate technical councils as to whether or not the Code Change Proposal should
be accepted, modified or rejected.
If a proposal is accepted or modified, it will then be incorporated into the next version of
the appropriate Alberta Safety Code.
Objectives
The Alberta Building, Fire and Plumbing Codes are objective-based codes. This means
that the objectives each Code attempts to address are clearly stated and every
provision in the Code is there to help achieve at least one of the stated objectives. It
follows that an objective-based code will only contain provisions that are related to
achieving one of its stated objectives.
The objectives of the Alberta Building, Fire and Plumbing Codes have been determined
by the Canadian Commission of Building and Fire Codes {CCBFC) and Alberta
Municipal Affairs, in consultation with the other provinces and territories. The objectives
of the Alberta Building, Fire and Plumbing Codes are listed in Part 2 of Division A of
each Code. Persons proposing the addition of a provision to one of the National Code
Documents should ensure that the proposed addition can be linked to one of the Code's
stated objectives.
The addition of a provision that cannot be linked to one of the currently stated objectives
would require the addition of at least one new objective or sub-objective. Although this
is not out of the question, the CCBFC, Alberta Municipal Affairs and the Safety Codes
Council would consider such an expansion of the scope of the Code in question only
after careful consideration and consultation.
Focus on Generic/W idespread Issues

It is impractical for the Alberta Safety Codes to deal with specific products or with
situations that arise only rarely. Code Change Requests should therefore be limited to
generic or widespread issues. Innovative products that are not yet covered by
standards or mentioned in the Codes are not necessarily excluded from use; they can
- 3- Page No.00215
/dlberla
M u n icip a l A ffa irs S /iftT i- C o o ts Co u n c il
be accepted by local authorities based on the provisions in the Codes regarding

alternative solutions (equivalents). Services, such as NRC’s Canadian Construction
Materials Centre, are available to assist authorities in evaluating such equivalence.
Similarly, unique situations are best dealt with by local authorities rather than swelling
the Codes with requirements that are seldom applied.
Summary
Code Change Requests should be framed in such a manner as to convince a council of
volunteer experts that there is a problem with certain existing requirements, an omission
in those requirements or that the current requirements do not adequately reflect the
state of the industry. The requests should also be accompanied by documentation to
support the case being made, including information on the likely costs of implementing
the requested change.
Each request should answer the following questions:
• Which one of the Alberta Safety Codes are affected by this request?
• What is the issue raised by the request?
• Which provision of the appropriate code addresses the issue?
• Which objective of the appropriate code addresses the issue?
• What is the proposed solution and how does it address the issue?
• What are the cost implications?
• What are the enforcement implications?
The Safety Codes Council has instructed the staff of Alberta Municipal Affairs to return
requests that are incomplete or unclear to their proponents. The staff of Alberta
Municipal Affairs is available to help proponents prepare suitable submissions, but the
onus is on the proponent to satisfy these criteria.
Disclaim er
The collection of personal information on this form is authorized under section 33 of the
Freedom of Information and Protection of Privacy (FOIP) Act and will be used to support
the process of evaluating proposed amendments to the Alberta Safety Codes. The
personal information will be managed in accordance with the privacy provisions of the
FOIP Act. Questions about the collection of this information can be directed to the
Safety Services branch of Alberta Municipal Affairs, at the address noted above.
By submitting this Code Change Request, you grant permission for all of the information
provided, including your name, company, and contact information, to be circulated to
staff of Alberta Municipal Affairs and members of the Safety Codes Council on an as
needed basis, including correspondance with you about the proposed amendment you
are putting forward. Any personal information will be deleted prior to further
promulgation of the proposed change beyond what has been detailed above.
Codes and Standards Contacts

The following organizations are responsible for the development of the various Codes
adopted in Alberta.
-4- Page No.00216
Liberia
M u n icip a l A ffa irs Sa fe ty Codes Co u n c il
1. Alberta Municipal Affairs

16 Floor Commerce Place, 10155-102 St.
Canada
• Alberta Building Code, as established by the Safety Codes Council and
published by the National Research Council of Canada
• Alberta Fire Code, as established by the Safety Codes Council and
published by the National Research Council of Canada
• Code for Electrical Installations at Oil and Gas Facilities, published by the
Safety Codes Council
• Alberta Electrical and Communication Utility Code, published by the Safety
Codes Council
• Alberta Private Sewage Systems Standard of Practice, published by the
Safety Codes Council *
2. Institute for Research in Construction
National Research Council of Canada
1200 Montreal Road
Ottawa, ON K1A 0R6
Canada
• National Plumbing Code of Canada 2005
3. Canadian Standards Association
5060 Spectrum Way
Mississauga, ON L4W 5N6
Canada
• CSA Standard Z98, “Passenger Ropeways”
• CSA Standard Z267, “Safety Code for Amusement Rides and Devices”
« CSA Standard B355, “Lifts for Persons with Physical Disabilities”
• CSA Standard Z185, “Safety Code for Personnel Hoists”
• CSA Standard B311, “Safety Code for Manlifts”
• CSA Standard B44, "Safety Code for Elevators”
• CSA Standard B51, “Boiler, Pressure Vessel and Pressure Piping Code"
• CSA Standard B52, “Mechanical Refrigeration Code”
• CSA Standard Z662, “Oil and Gas Pipeline Systems”
• CSA Standard B108, “Natural Gas Fuelling Stations Installation Code”
• CSA Standard B109, “Natural Gas for Vehicles Installation Code”
• CSA Standard B149.1, “Natural Gas and Propane Installation Code”
• CSA Standard B149.2, “Propane Storage and Handling Code”
• CSA Standard B149.5, “Installation Code for Propane Fuel Systems and
Tanks on Highway Vehicles”
• CSA Standard C22.1, “Canadian Electrical Code, Part I (20th Edition),
Safety Standard for Electrical Installations”

- 5- Page No.00217
L ib e ria
M unicipal Affairs Sa f e t y Codes Co u n c il
4. American Society of Mechanical Engineers International

Three Park Avenue
New York, NY 10016-5990
USA
• ASME Boiler and Pressure Vessel Code
• ASME Code for Pressure Piping, B31
■ B31.1, “Power Piping”, including Appendices A to G, J, II and III
■ B31.3, “Process Piping”, including Appendices A to E, K, L and X
■ B31.5, “Refrigeration Piping and Heat Transfer Components”
■ B31.9, “Building Services Piping”
5. American National Standards Institute
1819 L Street, NW, 6th floor
Washington, DC 20036
USA
• ANSI Standard K61.1, “Safety Requirements for the Storage and Handling
of Anhydrous Ammonia”
6 . National Fire Protection Association
1 Batterymarch Park
Quincy, MA 02169-7471
USA
• NFPA 58, “Liquefied Petroleum Gas Code”
• NFPA 59, “Standard for the Storage and Handling of Liquefied Petroleum
Gases at Utility Gas Plants"
1. Manufacturers Standardization Society
127 Park Street NE
Vienna, VA 22180
USA
• MSS Standard SP-25, “Standard Marking System for Valves, Fittings,
Flanges and Unions”
8 . Tubular Exchanger Manufacturers Association
25 North Broadway
Tarrytown, NY 10591
USA
• Standards of Tubular Exchanger Manufacturers Association
9. American Petroleum Institute
1220 L Street, NW
Washington, DC 20005-4070
USA
• API Standard 661, “Air Cooled Heat Exchangers for General Refinery
Services"

-6 -
Page No.00218
L ib e ria
M u n icip a l A ffa irs S ife t y C oots Co u n c il
For staff use only
Date Received:__
ALBERTA SAFETY CODES Assigned to: ____
CODE CHANGE REQUEST FORM File No.:_________
PCF No.:
Note: Use one form per code change proposal - duplicate form as necessary - print single sided.
Refer to the attached guidelines for information and guidance on how to properly complete this form.
Complete these forms in their entirety. Incomplete forms may be returned to the proponent or rejected.
Mail, fax or email to:
Alberta Municipal Affairs, Safety Services
10155-102 Street, Edmonton, Alberta T5J 4L4
Telephone 1-866-421-6929 Fax 780/427-8686
Email: safety.services@gov.ab.ca
The collection of personal information on this form is authorized under section 33 of the F re e d o m o f In fo rm a tio n a n d P rote ctio n o f
P riv a c y (FO IP) A c t and will be used to support the process of evaluating proposed amendments to the Alberta Safety Codes. The
personal information will be managed in accordance with the privacy provisions of the F O IP Act. Questions about the collection of this
information can be directed to the Safety Services branch of Alberta Municipal Affairs, at the address noted above.
By submitting this Code Change Request, you grant permission for all of the information provided, including your name, company, and
contact information, to be circulated to staff of Alberta Municipal Affairs and members of the Safety Codes Council on an as needed
basis, including correspondence with you about the proposed amendment you are putting forward. Any personal information will be
deleted prior to further promulgation of the proposed change beyond what has been detailed above.
Name:
Address:
Phone: ( ) Fax: { )
Email Address:
Contact me by: □ E-mail □ Fax □ Mail
□ Code Enforcement Official □ Builder / Contractor

Function: Cl Architect / Engineer / Designer □ Supplier / Manufacturer
□ Building Owners / Managers □ Home Owner / General Public
□ Other (please specify)
Code Document: Which of the Alberta Safety Codes are you proposing to change?
Code Reference: What is it being proposed to change (article, sentence, etc.)?

Page EMO?ob2l9'4
Problem : W hy should the existing provision be changed or, if proposing an addition to the code, what is missing and
which code objective does it address?
Proposed C h an ge/A ddition: W hat wording for the change/addition do you think should be used in the Code?
Justification /E xp lan atio n : How does the proposed change/addition address the problem?
Alberta Municipal Affairs Information Request 3P4A-R-PP88

PagenNo.PPzS"
C o st Im plications: Will the change/addition entail any added costs? Will it provide benefits measurable in monetary
terms? Provide detailed cost-benefit analysis where applicable.
E n fo rcem ent Im plications: Can the proposed change/addition be enforced by the infrastructure available to enforce this
code? Will enforcement require and increase in resources?
O th er C om m ents:
Alberta Municipal Affairs Information Reque

List Attached Supporting Material:
Alberta Municipal Affairs Information Request

Page'
Government p r o d u c t in c id e n t DATE:
O f Alberta H Field Report Information Sheet
A. PRODUCT INFORMATION:
Generic Name of Product: Model or Cat. No.:
Manufacturer: Electrical Ratings;
Name of Certification Organization:
Control or Listing #: Prod. Cat.:
Certification mark is on: (mark all that apply) Product □ Package □ Literature [U
Comments:
B. LOCATION OF PRODUCT:
Name:
Address: and/or Legal Description:
LSD: Sec: Twp: Rge: W Mer.
C. SUBMITTED BY:
Name: Title:
Employer: Tel:
Address: Fax:
D. NATURE OF TH E PROBLEM :
E. HAS PRODUCT BEEN R E JE C T E D BY TH E INSPECTION AUTHORITY? □ Yes □ No

FO R O FFIC E USE:
CO REPLY: Yes □ No □ DATE:
COMMENTS:
Submit Form to Technical Administrator: Municipal Affairs, Safety Services, 16in Floor, Commerce Place, 10155- 102 Street, Edmonton, AB T5J 4L4
Em ail: safety.services(g}qov,ab.ca Fax: 780-427-8686 Phone: 1-866-421-6929

Page No.00223
Government LOCAL FILE NUMBER
Of Alberta ■ electrical incident report form DATE
r 'N H u m a n F a ta lit y EDYes H u m a n In ju r y EDYes A n im a l F a tilit y EDYes

( d ic k o n e ) EHNo ( c lic k o n e ) EDNo ( c lic k o n e ) EDNo
Date o f A c c id e n t T im e o f Day
E xact Location o f A ccident
LSD Section T o w n s h ip Range W e st o f
D ETA ILS N am e D f Person In ju re d o r In v o lv e d O ccupation Age P hone No.
Address Postal Code
D escription o f In ju r y ( if any)
OF Em ployer Phone No.
Address Postal Code
D escription o f A ccide n t (s ta te fa c ts o nly )
A CCID EN T
V, J

Page No.00224
Print Form Reset Form
GAS INVESTIGATION REPORT
FO R O F F IC E U S E O N LY
Government
Gas File Number: I6100-G01-__
T h is p e r s o n a l in f o r m a tio n is b e i n g c o l l e c t e d u n d e r th e a u th o r ity o f th e S a f e ty C o d e s A c t
a n d w i l l b e m a n a g e d in c o m p lia n c e w ith th e F r e e d o m o f I n f o r m a tio n a n d
Fire File Number:
P r o te c ti o n o f P r i v a c y A c t.
REASON FOR INVESTIGATION______________________

| Fatality J Property Damage o f over $250 | Injury requiring professional medical attention | Carbon Monoxide Poisoning
SITE INFORMATION
Date of investigation; Time: Municipality:
Location of Incident - Full Address (A p t. S tr e e t, C it y /T o w n j OR (S e c . T w p . R g e . M e r .) Postal Code
Name of Occupant (L a s t. F ir s t. I n itia l) Address Phone Number
Name of Owner ( L a s t, F ir s t, I n itia l) Address Phone Number
APPLIANCE, VEHICLE OR OTHER EQUIPMENT

Description of item Make Year M odel Serial Number Licence No. Prov./State
INJURIES
WITNESSES
SAFETY CODES OFFICER INFORMATION

Date of incident Time of incident Reported by Was installation previously inspected? Permit#
J“ Yes p No
Fire Officer in Charge Position Assignment
Include a brief description o f incident on separate sheet o f paper and attach.
Photographs attached: f~ Yes No

Gas Officer Name (Print) E-mail address Phone Number
SCO Number Date report submitted Signature
F o rw a rd copy lo:
Alberta Municipal Affairs, Plumbing and Gas Administrator
16th Floor. 10155-102 Street Edmonton AB T5J 4L4, Phone: 1-866-421-6929. Fax: 780-427-8686, E-mail: safety .services@gov,ab.ca
------------------------------------------------------------------------------------------------------------------- Alberta Municipal Affairs Information Request 2015-R-008B
Page No.00225
alberta Municipal Affairs Report of Product Malfunction
Related to Plumbing and Gas Equipment Design
Date:
l. --------------------------------------------------- 1
A. PRODUCT INFORMATION
Type of Equipment Manufacturer
Model Number Serial Number
Equipment Ratings/Rating Plate Information
B. CERTIFICATION
Additional Certification Markings & Information
C. OWNER OF PRODUCT
Nam e Telephone Number
( )
Address S tre e t T o w n /C it y P ro vin ce P o s ta l C o d e Fax Num ber
( )
Location of Equipment (S tr e e t a d d re s s , le g a l a d d r e s s a n d a c tu a l lo c a tio n in bu ild in g )
D. SOURCE OF REPORT
Nam e o f Person W ho Inspected The Product Title / SCO Number
Nam e o f Organization Telephone Number Fax Number
( ) ( )
Address S tre e t T o w n /C it y P rovince P o s ta l C ode Jurisdiction
E. DESCRIPTION OF EQUIPMENT FAILURE

(A tta c h a n e x tra p a g e i f m o re s p a c e is re q u ire d .)
Send this completed form to: Alberta Municipal Affairs

Safety Services
16th Floor 10155 102 Street
EDMONTON AB T5J 4L4
Telephone: 1-866-421-6929 Fax: 780-427-8686
T h is in fo rm a tio n is b e in g c o lle c te d fo r th e p u rp o s e s o f in v e s tig a tin g a n u n s a fe co n d itio n in a c c o rd a n c e w ith th e S a fe ty C o d e s A ct.

Q u e s tio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n c a n b e d ire c te d to P u b lic S a fe ty D iv is io n , S a fe ty S e rv ic e s , 1(5th F lo o r, C o m m e rc e
P la c e , 1 0 1 5 5 - 1 0 2 S tre e t, E d m o n to n , A lb e rta T 5 J 4 L 4 , 1 -8 6 6 - 4 2 1 -6 9 2 9 .

PSD1271 (2007/03) Page No.00226
This form is to be completed when a product or equipment failure occurs due to
design, manufacturer, or standard deficiency. This provides information that can
be used to identify repeat product failure, which will be forwarded to the
appropriate certification agency or standards body, by Alberta Municipal Affairs.
The failure may be a result of:

• the unit not being manufactured according to the standard;
• the unit failing to operate as intended;
• a component part failure for reasons other than abuse or long term
operation.
This form is not to be used for incorrect installation or application.
Product Information
Define the type of equipment, e.g. plumbing fixtures, piping, furnace, water
heater, etc. This includes specific information on rating plate, e.g. BTU Rate,
orifice size, manifold pressure, plumbing product number and standard number
stamped on material, etc.
Identify markings of certification agency certifying equipment. Include the number
appearing on the certification mark.
Owner of Product
Give the name and address of the owner of the fixture, appliance or equipment.
Also, give the street address, legal description and the location in the building of
the equipment or appliance.
Source of Report
Give the name of the person who inspected the product in case future contact is
necessary. Ensure the jurisdiction is completed.
Description of Equipment Failure

Describe the failure of, or problem with, the equipment and the determined
cause. Include any action taken to correct the problem and state if the problem
is corrected (attach extra pages if required). Include any related installation
inspection reports.

PSD1271 (2007/03) Page No.00227
Governm ent
of A lberta ■
Municipal Affairs
SER VIC E C O M PLETIO N NOTIFICATION
Lot B lk Plan
Permit No _ L o c a tio n
Q tr S ec Tw p Rge Mer
Permit Issurer_
Installation name
Address
C o n tr a c to r / In s ta lle r
Name ________
Address
Phone
I hereby certify that the piping system has been installed and tested:
i) In compliance with the Safety Codes Act & Regulations and CSA B149.1 and
ii) this installation is ready for gas service activation.
Please enter number of appliances and total input BTU rating for each of the following
H ou se F u m a ce (s) W a te r h e a ter BBQ F ireplace R ange
D ryer G arage O th e r O th e r O ther
Air Test: Duration PSI
Gas Service Is Connected to Meter yes ______________ No
Signature
Print Name
Gas Fitter Certificate No.
Date
This form is to be com pleted and faxed or e-m ailed to the Perm it Issuer and the Gas S u pplier before the
gas service will be unlocked.

Page No.00228
Safety Services
250, 7015 Macleod Trail South
Government
Calgary, Alberta T2H 2K6
Telephone: 1-866-421-6929
Propane Vehicle Inspection
PARTI
New Installation Re-Inspection \ ^ \ Private Vehicle ( ^ ] Commercial
Car Truck [ ^ J Taxi j ^ j School Bus j Commuter Bus Q j
I have been instructed on the safe operation and

maintenance of the propane fuel system on this Vehicle -----------------------------:-------------------------------
and that any modification Will VOID this inspection. Signature of Owner / Operator
PART 2
Fuel Tank(s) Size Solenoid Valve Yes Q No n
Stop Fill Valve Yes □ No D

Fuel Tank(s) Serial Number(s)
1st. 2nd.
Manufacturer
Fuel Tank(s| CRN Number(s)
1 s t. 2nd.
1 Model
Manufacturer Date of Manufacture Retest Date
1 s t.
Tank(s) Location Enclosed External
2nd.
Gas-tight assembly Yes Q No Q
Remarks
PART 3 Do not com plete this part or apply the Vehicle Label until all Inspection Standards have been met.
I hereby certify that the vehicle describ ed above has been inspected and the propane fuel system is in com pliance with the A ct and R egulations.
Permit Number Inspection Date Installer's Certificate Number

y y m m d d
LP 53630
__ I__l__ l l i i. i 1 . I ...
C c rti'ic d Inst,A |berta Municipal Affairs Information Request 2015-R-0088
Page No.00229
PSD 1310 (2008/07) O R IG IN A L - A lb e rta M u n ic ip a l A ffa irs Y E L L O W - V e h ic le O w n e r W H ITE - P e rm it H o ld e r
Capital Printing & Forms
f \ m fs * f* ^ f i f ^ ^
Government
of Alberta ■ Safety Services Inspection Report
Public Safety Division, Safety Services Branch
16th Floor, Commerce Place, 10155-102 Street, Edmonton AB T 5 J 4L4
Telephone 1-866-421-6929 / Fax 780-427-8686
safety.services@gov.ab.ca / http://www.municipalaffairs.gov.ab.ca/index.cfm
File
Name (Last, M iddle, First) Date
Legal Address
Mailing Address
Telephone Number (include area code) Cell Phone Number (include area code) E-Mail Address
Installer Telephone Number (include area code)
Address
Type of Inspection CD Building ED Electrical EH Gas CD Plumbing CD PSDS CD Deficiencies

Comments
Sign and return upon completion of listed deficiencies.
SCO Signature Designation Number
Owner’s Signature Date
White: Owner Yellow: Installer Blue: SCO Pink: File Copy
PSD1387 (2008/03) Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00230
C orporation
S coring C o rporation C h ecklist Result
2012-2013 Corporate Score For Perform ance Measurement
F ile # 16020- 0
C o rpo ra tion : ___________________________________________ Corporate Score: # D IV /0 !
A ccredited D iscipline s: 0 A ccred itatio n No. cooo
( 5.) Part 2 - File Review Checklist - Safety Permits BEPG
CONSTRDOCUM VERIFICATION
SITE Discipline Score
Discipline Name P R O JE C T REVIEW /PLAN OF FILE C LO S U R E
INSPECTION COMPLIANCE
REVIEW
Building n/a n/a nla n/a n/a N/A

Electrical N/A N/A N/A N/A N/A N/A
Plumbing n/a n/a n/a n/a n/a N/A
Gas n/a n/a n/a n/a n/a N/A
PSD S n/a n/a n/a n/a n/a N/A
M a n a g e m e n t P r o c e s s M o n it o r in g
(3-1
Request for
Specific
(6.) (2 )
QMP Checklist Inspection
Forms
Specific
Variance
Section Name SectionA SectionB Variances Forms Section Score
QMP #DIV/0! #DlV/01 N/A N/A #DM0l
l(N.) AAA ~j Name of Specific Tab that contains the Monitoring Questions
(N.) The order that each group of checklist questions are answered.
(Located within the yellow boxes.)
Q M P C h e c k lis t
SectionA | f SectionB l
, Available Earned
Section A Jo in t s 8 Earned Poin<s Section 8 Points Points
QMP Verification 0.0 0.0 Declaration of Status 0.0 0.0

Operating Policies Relating to Compliance and Compliance
Scope of Accreditation 0.0 0.0 Monitoring 0.0 0.0
Management Policy and Commitment to the QMP 0.0 0.0 Policies for Building (Use N/A if Corporations is not accredited) 0.0 0.0
Organization Chart 0.0 0.0 Policies for Electrical (Use N/A if Corporations is not accredited) 0.0 0.0
Provision and Training of Safety Codes Officers 0.0 0.0 Policy for Gas (Use N/A if Corporations is not accredited) 0.0 0.0
Corporation Staff 0.0 0.0 Policy for Plumbing (Use N/A if Corporations is not accredited) 0.0 0.0
Contracted Aqency 0.0 0.0 Documentation 0.0 0.0
Enforcement 0.0 0.0 Records Retention. Retrieval, and Disposition 0.0 0.0
Variances 0.0 0.0 Proqram Review 0.0 0.0
Accidents 0.0 0.0 Non-conformance and Corrective Actions 0.0 0.0
Revision & Control System 0.0 0.0
N/A N/A
_________ N/A_________________ N/A
Inspection Report Form l I V a r ia n c e 1
(2.) Inspection (3.)

Report Form Rea For
Specific
(N.) AAA Name of Specific Tab that contains the Monitoring Questions Variance
NN Number of points allocated
NN Number of points earned <4.)
The order that each group of checklist questions are answered. (Located within the yellow boxes.) Specific
The range of points allocated to the identified section. Variance

12/15/2015 Page No.00231
i'qoii'dosklop'A D'dav*d pFili:psOeiMop'Corpor* fo r*v+«w ic o n th*at with Summary-Corporate Scon
A C C R E D IT E D C O R P O R A T IO N - IN S P E C T IO N R E P O R T F O R M C H E C K L IS T
Corporation: Accreditation Number: C000
Discipline: Reviewers):
Review Date: File Number: 16020-
Does the Corporation use an Inspection Report?
Do the Corporation’s inspection report form s capture the follow ing required inform ation Actual Available
Score Score
Note: Questions can only be answered with Yes or No for accredited discipline(s) otherwise for non-accredited discipline(s) use N/A.. 1 = Yes 1 = Yes
0 = No 0 = No
QUESTION B E G P PS COMMENT N/A = info N/A - info
1 File number N/A N/A
2 Discipline N/A N/A
3 Corporation name N/A N/A
4 Date N/A N/A
6 Contractor name, address, and phone number N/A N/A
7 Legal description, civic address, or unit name of the undertaking N/A N/A
8 Stage(s) of work being inspected N/A N/A
9 A description of the work in place at the time of inspection N/A N/A
10 All observed deficiencies N/A N/A
All observed unsafe conditions (a n y condition that, in th e opinion o f a

11 S C O , co uld resu lt in p ro p e rty lose, injury, o r death, a n d is n o t a N/A N/A
situation o f im m in en t serious da ng er)
All observed situations of imminent serious danger and the action N/A N/A
12
taken by the SCO to remove or reduce the danger
Name, signature, and designation number of the SCO conducting the N/A N/A
13
inspection.
SCORING 0 I 0 1
NUMBER CORRECT N/A for this term
AVAILABLE POINTS N/A N/A N/A Points Scored

Page No.00232
A C C R E D IT E D C O R P O R A T IO N FILE R E V IE W C H E C K L IS T - R E Q U E S T F O R S P E C IF IC V A R IA N C E
Corporation: 0 Accreditation Number cooo

Discipline: 0 Reviewers) 0
Review Date: 1/0/1900 File Number: 16020- 0
Are there files?
Note: Questions can be answered with Yes, No or N/A Actual Available

1 = Yes 1 = Yes
FILE NUMBER
o
ii
ii
o
z
z
QUESTIONS OBSERVATIONS
XX XX XX XX XX
N/A = info N/A = info
1 Is the document identified as a Request for Specific N/A N/A
2 Is there an explanation for the Variance? N/A N/A
3 Is there a date of request? N/A N/A
Is there a name and address of the owner and/or owner's

4 N/A N/A
agent requesting the Variance on the form?
5 W as the Code or Standard to be varied listed? N/A N/A

6 Is there details of the proposed Variance? N/A N/A
7 Is there a reason for the Variance? N/A N/A
8 Is there supporting documentation provided? N/A N/A
9 Is the Address and/or legal description of the property listed? N/A N/A
10 W as the act or regulation properly referenced in the variance N/A N/A
11 Is there a Declaration of Understanding on the Variance? N/A N/A
12 Is the Advisement of the Offence of Non-compiiance N/A N/A
13 Is the signature of the owner or owner's agent on the N/A N/A
SCORING - Request fo r Specific Variance SCORING - Request fo r Specific Variance 0 0
SCORING - Specific Variance SCORING - Specific Variance 0 0
SCORING - Total SCORING • Total 0 0
NUMBER CORRECT 0 / _______0 = _______________________ N/A_______________________for this term
AVAILABLE POINTS N/A X N/A = _____________________________________________ N/A

Page No.00233
A C C R E D IT E D C O R P O R A T IO N F IL E R E V IE W C H E C K L IS T - S P E C IF IC V A R IA N C E
Corporation: __________________ 0__________________ Accreditation Number:____________ COOP
Discipline: __________________ 0__________________ Review ers) ______________ 0 _
Review Date: _______________ 1/0/1900_______________ File Number: ________ 16020- 0
Are there files?

Actual Available
Note: Questions can only be answered with Yes or No. do not use N/A Score Score
1 — 1CO 1 “ 1CO
FILE NUMBER 0 = No 0 = No
QUESTIONS OBSERVATIONS
XX XX XX XX XX
1 W as the Specific Variance properly requested? N/A N/A
2 Is there an explanation for the Variance? N/A N/A
3 Is there an issue date? N/A N/A
Is the owner and/or contractor information on the

4 N/A N/A
Variance?
5 Is there a reason for the Variance? N/A N/A
6 Is there details for the Variance? N/A N/A
7 Is the Variance site-specific? N/A N/A
Is the address and/or legal description of the property

8 upon which the thing, process or activity which is the N/A N/A
subject-matter of the variance is located?
W as the act or regulation properly referenced in the

9 N/A N/A
variance requested?
Is the Advisement of the Offence of non-compliance
10 N/A N/A
recorded on the Variance?
Is the SCO identification (SCO Name, SCO and
11 Designation Number, and discipline) and signature on N/A N/A
the Variance?
Is the Accredited corporation or agency employing the
12 N/A N/A
SCO identified on the Variance?
Is there evidence that the Variance was submitted to the N/A N/A
13
appropriate Technical Administrator and Owner?
SCORING 0 0
NUMBER CORRECT 0 / 0 = _______________________ N/A_______________________for this term

Page No.00234
ACCREDITED CORPORATION - FILE REVIEW CHECKLIST - INSPECTION FILES
Accreditation
C000
Corporation: ______________________________________________ Number:
Discipline: ___________________ Building___________________ Reviewers) 0
Review Date: ______________________________________________ File Number: 16020- 0
W as there worfc Performed? _________
Are there files? _________
Note Question can be answered with either Ye s or No or N/A, any question that is shaded cannot be answered with N/A.
P R O JE C T
Actual Available
Score Score
1 = Yes 1 = Yes
C O R P O R A TE FILE NUMBER
0 = No
ii
o
o
z
QU ESTIO N S O BSERVA TIO N S
XX XX XX XX XX
Were construction documents (sp ecs, drawings, Peng/AAA

1 approval, soil report) required by the QMP or a S C O ? (If N N N N N N/A N/A
YES complete question 1.a, if No go to question 4)
Were the docum ents required by the QMP or the S C O

1a N/A N/A N/A N/A N/A N/A N/A
received prior to project start up?
o.oo 0.00 n/a

Page No.00235
Accreditation
0 COOO
Corporation: Number:
Discipline: Building Reviewer(s) 0
Review Date: File Number: 16020- 0
CO N STRU CTIO N DOCUMENT R EVIEW (PLAN REVIEW )
Actual Available
Score Score
1 = Yes 1 = Yes
C O R P O R A TE F IL E NUMBER 0 = No
n
o
o
z
Q U ESTIO N S O BSERVA TIO N S
XX XX XX XX XX
Is a Construction Document Review (Plan Review) required

2 by the QMP or an S C O ? (If YES complete questions 2.a - 3; If N N N N N N/A N/A
NO go to question 4)
W as the Plan Review conducted in the time frame allowed

2.a N/A N/A N/A N/A N/A N/A N/A
by the QMP?
Does the Plan Review Document meet the requirements of

2.b N/A N/A N/A N/A N/A N/A N/A
the QMP?
W as Plan Review performed by an S C O with the correct

2.c N/A N/A N/A N/A N/A N/A N/A
level of competency?
2.d W as one set of construction docum ents (plans) retained? N/A N/A N/A N/A N/A N/A N/A
2.f Was the Plan Review Report retained on file? N/A N/A N/A N/A N/A N/A N/A
Does the Plan Review contain items requiring corrections?

3 N N N N N N/A N/A
(If YES answer questions 3.a. If NO go to question 4).
Is there evidence of follow-up to items requiring

corrections?
0.00 0.00 n/a

Page No.00236
Accreditation
0 CDOO
Corporation: Number:
Discipline: Building Reviewers} 0
S IT E IN SPECTIO N
C O R P O R A T E FILE NUMBER
Q U ESTIO N S O B SER VA TIO N S
XX XX XX XX XX
Were the correct Inspection form(s) used for each inspection?

4 N/A N/A
Y/N
s Were the inspection form filled out completely? Y/N N/A N/A
Were the stage(s) of the project noted on the inspection

6 N/A N/A
report(s)? Y/N
Were the stages of work inspected as required by the terms of

7 N/A N/A
accreditation? Y/N note: this could be an NA
Were the S C O 's certification level appropriate for each

8 N/A N/A
inspection? Y/N
Were the minimum number of inspections conducted as
9 N/A N/A
required by the QMP? Y/N
Were there any noted deficiencies on any inspection

10 reports? (If yes, complete question 10.a, if no use N/A for N N N N N N/A N/A
10.a)
Were the noted deficiencies followed up as required by the

QMP?
Were there any unsafe conditions observed or noted? (If

11 N N N N N N/A N/A
yes. complete question 11.a. if no use N/A for 11.a)
Were the unsafe conditions followed up as required by the

11 a N/A N/A N/A N/A N/A N/A N/A
QMP?
Are there copy(ies) of the inspection report(s) in the

12 N/A N/A
Corporation's file? Y/N
0.00 0.00 n/a

Page No.00237
Accreditation
CQOO
Corporation: 0 Number:
Discipline: Building Reviewer(s) 0
V ERIFICATIO N OF CO M PLIAN CE
C O R P O R A TE FILE NUMBER
QU ESTIO N S O B SER VA TIO N S
XX XX XX XX XX
Is there a Verification of Com pliance (VOC) on file? (If yes. N/A N/A
13 N N N N N
complete questions 13.a - 13.fa s indicated in the QMP)
13 a W as the document identified as a V O C? N/A N/A N/A N/A N/A N/A N/A
13.b Did the VO C include the Name and Title of the provider? N/A N/A N/A N/A N/A N/A N/A
Did the VO C indicate how it was received? (Verbal, phone. N/A N/A
13,c N/A N/A N/A N/A N/A
fax etc)
13.d Did the VO C have a date accepted by the S C O ? N/A N/A N/A N/A N/A N/A N/A
13.e Did the VO C have the signature of the S C O accepting it? N/A N/A N/A N/A N/A N/A N/A
Did the VO C have the Designation # of the S C O accepting N/A N/A

13.f N/A N/A N/A N/A N/A
it?
0.00 0.00 n/a
F IL E C L O S U R E
Actual Available
Score Score
1 = Yes 1 = Yes
C O R P O R A T E FILE NUMBER 0 = No
o
z
o
11
QU ESTIO N S O B SER V A TIO N S
XX XX XX XX XX
Does the Corporation have a process for file closure as N/A N/A
14 N N N N N
required by the QMP? Y/N
14a Did the Corporation follow their process for file closure? N/A N/A N/A N/A N/A N/A N/A
0.00 0.00 n/a

Page No.00238
ALBERTA MUNICIPAL AFFAIRS SUPPORT MANUAL Accredited Corporate QMP Monitoring Checklist
A C C R E D IT E D C O R P O R A T IO N - QMP M O NITO RING C H E C K L IS T
Corporation: Accreditation Number: ^000
Contact (responsible for Q M P): Fax Number:
Phone: E-mail:
Name of AMA Reviewer(s): 0 Uniform QMP (Y or N): V

" A lb e rta M u n ic ip a l A ffairs
Review Date: 1/0/1900 File Number 16020-0
PLANNING CONSIDERATION:
HOW IS S A F ET Y SERV ICE

DATE QMP PROVIDED
DISCIPLINE SCO PE AGENCY NAME
SIGNED B Y
Corporation Agency
see
Building
Electrical 28-Jun-05 CEC
Gas
Plumbing
COM PLETED SAM PLE TIME FRAME Start Date: Finish Date:
if Closed Flies Sample Size # Closed Files Sample Size tt Closed Files Sample Size # Closed Files Sample Size
3 or less All 91-105 10 17 2201-2600 24
641-730
4 to 15 4 106-190 11 18 2601-3000 25
731-820
16-30 5 191-280 12 19 3001-3400 26
821-910
31-45 6 281-370 13 20 3401*3800 27
911-1000
46-60 7 371-460 14 21 3801-4200 28
1001-1400
61-75 8 461-550 15 22 4201-4600 29
1401-1800
76*90 9 551*640 16 23 4601 or more 30
1801-2200
FILE SAM PLE SIZE (by Discipline)
Total # of (discipline)
# of files to be reviewed (as per sample size from
Disciplines closed/completed files from the file
File Sample Size Selection Chart)
sample time frame
Building
Electrical
Gas
Plumbing
Private Sewage
VARIANCES
# of files to be reviewed (as per sample size from

Total # from the file sample time
Variance File Sample Size Selection Chart) use the
frame
checklists to review the variances and orders
Actual Available
0 0 Score Score
1 = Yes 1 = Yes
QMP Verification 0 = No 0 = No
Y N N/A COMMENT
Is the Corporations QMP the same as the

1 N/A N/A
QMP on file with the SCC? (Yes or No only)
1
Have there been any changes in the QMP
2 since the last review? Please summarize. N/A N/A
If yes go to question 2.a (if NO use N/A for 2.a}
1
Is there evidence that these changes were
approved by the Administrator of
2.a N/A N/A N/A
Accreditation prior to implementation?
(Letter of transmittal)
0.00 0.00 Points

0% % earned
0.0 points available
0.0 points earned

Page No.00239
Corporation: Accreditation Number: COCO
Contact (responsible for QMP): Fax Number:
Phone: E-mail:
Name of AMA Reviewer(s): 0 Uniform QMP (Y or N): V

’ ’ A lb e rto M un ic ip a l A ffa irs
Review Date: 1/0/1900 File Number 16020- 0

Scope of Accreditation:
Y N N/A COMMENT
3
Does the Corporations service delivery policy
match the scope of accreditation on their
QMP? (Yes or No only) if N/A N/A
4
Does it appear that all work performed by the
corporation is in keeping with their
1 N/A N/A
i
accreditation? (Yes or No only)
Are all projects within the care and control of

5 N/A N/A
the accredited body? (Yes or No only)
Is there a person responsible for the

6 N/A N/A
administration of QMP? (Yes or No only)
Does the Corporation have processes in
7 place to obtain permits for disciplines they
are not accredited in? (Yes or No only) si N/A
0.00
N/A
0.00
0%
Points
% earned
0.0 points earned
Management Policy and Commitment to the QMP
Y N N/A COMMENT
Is there an organization statement of
8 N/A N/A
commitment in the QMP?
1
Does the QMP recognize the authority of
9 N/A N/A N/A
see?
Does the Corporation recognize the

10 independence of the SCO to make decisions N/A N/A N/A
pertaining the Safety Codes Act?
Is there a person named that is responsible

11 N/A N/A N/A
for effectiveness of the QMP?
Does the QMP recognized that the S C C has

12 the authority to ensure adherence to the N/A N/A N/A
QMP?
0.00 0.00 Points
0% % earned
0.0 points earned
Section 2 - Organization Chari
Y N N/A COMMENT
Does the corporation use their own staff
14 for S C O s? If yes go to questions 14.a-14d N N/A N/A
(if NO use N/A for 14.a-14,d)
vsv
14.a
Are the SCO s working for the Corporation
appropriately certified? (use Y or N only) i N/A N/A
0.00 0.00 Points

0% % earned
0.0 points earned
Corporation Staff
Does the Corporation have a policy to

Y
1
N N/A COMMENT
1
ensure their Safety Codes Officers N/A N/A
14.b
maintain their competency levels? (use
Y or N only)
Does the Corporation maintain a registry

of SC O s they employ, including the SCO s
I N/A N/A
1
14.c level of certification, and designation of
powers number? (use Y or N only)
Does the Corporation have a record of

14.d QMP training for the SC O s they employ?
(use Y or N only)
1 N/A
0.00
N/A
0.00
0%
Points
% earned
0.0 points earned

Page No.00240
Corporation: Accreditation Number: coo°
Contact (responsible for Q M P): Fax Number:
Phone: E-mail:
Name of AMA Reviewer(s): 0 Uniform Q M P fY or N): Y

"A lb e r ta M u n ic ip a l A ffairs
Review Date: 1/0/1900 File Number 16020-0
Contracted Agency
Y N N/A COMMENT
Does the Corporation use the services of
16 an accredited agency? (Yes or No only) (If N N/A N/A
NO 16.a - 16.h are all N/A)
I
l i
Does the Corporation have a signed
contract or other form of service
15.a N/A N/A
agreement with the accredited agency on
file? (use Y or N only)
Does the Corporation's contract with the
accredited agency require a registry of
15.b
SCO s the agency employees? (use
1 N/A N/A
11
Y or N only)
Does the Corporation's contract with their

agency address the certification of Safety
15.c N/A N/A
Code Officers (SCO s) and ensure proper
DOP? (use Y or N only)
Does the Corporation's contract with their

accredited agency address QMP training
15.d N/A N/A
for agency S C O s? (use Y or N
only)
n
15.e
agency address the ownership of records
pertaining to the services provided under
I N/A N/A
the Safety Code Act? (use Y or N
only)

1
I
Accredited Agency address the return of
15.f N/A N/A
all Corporation files upon termination of
the contract? (use Y or N only)
Does the Corporation have a regular

agency monitoring program in place in
15.g
accordance with their QMP?
Y or N only)
(use y 1 N/A N/A
Does the contract include a transition

15.h clause in the event of the termination of
the contract? (use Y or N only)
y i
i
N/A N/A
0.00 0.00 Points

0% % earned
0.0 points earned
Enforcement
Y N N/A COMMENT
Does the Corporation have available the

appropriately certified SCO s who may issue
17 N/A N/A
variances in accordance with the S C A and
S C C policy? (Yes or No only)
Does the Corporation have a policy in place

18
that address how the Corporation authorizes 1
SCO to issue variances on it's behalf? (Yes N/A N/A
or No only)
0.00 0.00 Points

0% % earned
0.0 points earned

Page No.00241
Corporation: Accreditation Number: C000
Phone: E-mail:
Name of AMA Reviewer(s): 0 Uniform QMP (Y or N|: V

"A lb e rta M u n ic ip a l A ffa irs

Accidents
Y N N/A COMMENT
Is the Corporation reporting all applicable
19 incidents/acddents required by the Safety 1 N/A N/A
Codes Act regulations? (Yes or No only)
1
0.00 0.00 Points
0% % earned
0.0 points earned
Declaration of Status
Y N N/A COMMENT
Do SCO s appear to have authority to make

20 independent compliance assurance decisions N/A N/A
l
without undue influence? (Yes or No only)
0.00 "o.oo Points

0% % earned
0.0 points earned
Section 6 - 0 aerating Policies Relating to Compliance and Compliance Monitoring

Y N N/A COMMENT
Does the accredited corporation have
documented policies & procedures related to
21
compliance monitoring in accordance with 1 N/A N/A
their QMP? (Yes or No only)
22
Does the Corporation have a record of all
work performed under their accreditation?
(Yes or No only)
n
1
N/A N/A
0.00 0.00 Points

0% % earned
points earned
Section 6a - Policies for Building (Use N/A if Corporations is not accredited)
Y N N/A COMMENT
For the building discipline does the
Corporation have a written policy for
establishing inspection requirements of each
23 N/A N/A
project or category of projects in accordance
with their QMP? (if accredited use Yes or No
only)
Did they follow their policy and procedures

1
24 for the required inspections? (Use N/A if 23 N/A N/A N/A
is NO)
0.00 0.00 Points

0% % earned
0.0 points availabie
0.0 points earned
Section 6b - Policies for Electrical (Use N/A if Corporations is not accredited)
Y N N/A COMMENT
For the electrical discipline does the
1
establishing inspection requirements of each
25 N/A N/A
project or category of projects in accordance
with their QMP? (if accredited use Yes or No
only)
Does the Corporation use a quality control

26 program for compliance monitoring? If N N/A N/A
YES go to question 26.a (if NO use N/A for 26.a)
1
Does the Corporation follow their
2G.a procedure for the Quality Control program N/A N/A N/A
and/or other required inspections?
0.00 0.00 Points

0% % earned
0.0 points earned

Page No.00242
A C C R E D IT E D C O R P O R A T IO N - QMP M O N ITO RIN G C H E C K L IS T
Corporation: Accreditation Number: coo°
Contact {responsible for Q M P): Fax Number:
Phone: E-mail:
Name of AMA Reviewers): 0 Uniform QMP (Y or N): Y

" A l b i n a M u n ic ip a l A ffairs

Section 6a - Policy for Gas (Use N/A if Corporations is not accredited)
Y N N/A COMMENT
v\Vs
For the gas discipline does the
27
establishing inspection requirements of
each project or category of project in 1 N/A N/A
1
accordance with their QMP? (if accredited
use Yes or No only)
Did they follow their policy and

28 procedures for the required inspections? N/A N/A N/A
(Use N/A if 27 is NO)
1
Does the Corporation use a "Spot Check"
program for compliance monitoring? If
29 N/A N/A
yes go to question 29.a (if NO use N/A for
29.a)

29.a procedures for the "Spot Check" program N/A N/A N/A
0.00 0.00 Points
0% % earned
0.0 points earned
Section 6a - Policy for Plumbing (Use N/A if Corporations is not accredited)
Y N N/A COMMENT
1
For the plumbing discipline does the
establishing inspection requirements of
30 each project or category of project in N/A N/A
accordance with their QMP? (i.e.: how are
1
projects assigned to catagory(ies)) (if
accredited use Yes or No only)

31 procedures for the required inspections? N/A N/A N/A
(Use N/A if 30 is NO)
k\\\
Does the Corporation use a "Spot Check"
program for compliance monitoring? If
s
32 N/A N/A
yes go to question 32.a (if NO use N/A for
32.a)

32.3 procedures for the "Spot Check" program N/A N/A N/A
0.00 0.00 Points

0% % earned
0.0 points earned
Section 7 - Documentation
Y N N/A COMMENT
Must have an explanation answering N or N/A
Is there a record of all work undertaken by
33 Corporation? (this includes maintenance N/A N/A N/A
work)
0.00 0.00 Points

0% % earned
0.0 points earned
Section 8 • Records Retention, Retrieval, and Disposition
Y N N/A COMMENT
• \s\
Are the records retained in accordance with

34 N/A N/A
the QMP? (Yes or No only)
If
35 Are the records retrievable? (Yes or No only) N/A N/A
i 0.00 0.00 Points
0% % earned
0.0 points earned
Program Review
Y N N/A COMMENT
Is there documented evidence that internal
36 reviews are being performed as required by
the S C C ? (Yes or No only)
i
ss
N/A N/A
0.00 0.00 Points

0% % earned
0.0 points earned

Page No.00243
A C C R E D IT E D C O R P O R A T IO N ■ QMP M O NITO RING C H E C K L IS T
Corporation: Accreditation Number: CQOQ
Phone: E-mail:
Name of AMA Reviewer(s): 0 Uniform QMP (Y or N>: V

“ A lb e rta M u n ic ip a l A ffa irs
Non-conformance and Corrective Actions
Y N N/A COMMENT
Were there any non-conformances? If YE S
37 go to question 37.a (if NO use N/A for N/A N/A
37,a)
1
Were non-conformances recorded as
37.a N/A N/A N/A
required by the QMP
0.00 0.00 Points

0% % earned
0.0 points earned
Revision & Control System
Y N N/A COMMENT
38
Does the corporation have a process in place
to review the QMP? (Yes or No only) i N/A N/A
39
to amend the QMP? (Yes or No only) i
It
N/A N/A

40 lo submit QMP amendments to the S C C and
QMP holders? (Yes or No only)
i N/A N/A
0.00 0.00 Points

0% % earned
0.0 points earned

Page No.00244
NEW HOMEBUYER PROTECTION PROGRAM
Credit Transfer
Client Information
C o n ta ct N a m e : ___________
C o m p an y n a m e : ___________
R eg istration #: ____________
Details/Reasons for Adjustment:
Original Payment Information:
C h eq u e # o r T ransactio n ID: ____________________________
A m o u n t: ___________________________________________________
D a te o f O rigin al T ra n s a c tio n :____________________________________
Processed by: ___________________________ Date:

Page No.00245
Governm ent De-enrollment Request
Registration Form Unit ID:
Warranty Provider Contact Name Telephone Number
Builder Name Contact Name Telephone Number
Home Owner Contact Name Telephone Number
Property Information
LINC Municipality
Street Number Street Name Number Suffix Street Type Street Direction Postal Code
Lot/Block/Plan
Lot Block Plan
A T S Standard Format: [LGS]-[QTR]-SEC-TW P-RGE-M ER
[ ] - [ ]- - -
A T S Non-Standard Format: TYPE-LOT-TW P-REG-M ER
Units
Warranty Policy Number:
Reason for De-enrollment
What Stage of Construction is the Home Currently At? (please fill out all that are completed)
| | Foundation Q Drywall Q Mechanical Systems | | Framing
| | Insulation Q Exterior Siding Q Finishing | | Other
Is there a purchaser? I~~l Y e s Q No If yes, provide contact information:
Has a building permit been issued? CH Y e s |~~1 No Permit Number: Permit Issuer:
Please complete and sign the below statement:
I . _____________________________ _____________________________ formally request that the property address above be de-enrolled from the New
Home Buyer Protection System.
____________ _______________________ X _________________________

Date (yyyy-m m -d d) Printed Name Signature
Refund Policy New Home Buyer Protection Office

- Any request for a refund must be in writing and must contain the following information: Alberta Municipal Affairs
- Correct Name of person or Business the refund will be issued to 16th Floor, Commerce Place
- Current address to send the refunds to
• Reason for refund (i.e. cancellation; application not approved; etc.) 10155-102 Street
- Identify the payment made (i.e. registration numbers; date o f registration; legal land) Edmonton, Alberta T5J 4L4 Canada
- All refund requests must be received within 30 business days or payment
- All refund requests will be reviewed by the department and must be approved Tel 1-866-421-6929
- No refunds will be issued for $500.00 or less Fax 780-427-2538
• Payment made by Credit Card win be issued back to the sam e card within 3 0 days from the receipt of the written request.
In the event of a batch upload or payment made by a 3rd party, the refund will be refunded back to the person/company requesting the refund. Website; www.homewarranty.alberta.ca
- Payment m ade by cheque, a refuna will be issuea back within 4 5 days.
- All refund requests are to be sent to the New Home Buyer Protection Office. Email: HomeWarranty.inquires@gov.ab.ca
NHBPB0009 (2015/05)
Page No.00246
New Home Buyer Protection System (/MinistryConsole)
Current User: NHBPS Test_Staff 1
Builder Search
Search For (pick at least one):
s’ Residential Builders
•f Owner Builders
Search By:
B u ild e r Name:
Builder Name
N H B P O B u ild e r ID :
NHBPO Buiider ID
W P B u ild e r ID :
WP Builder ID
Q. Search
Actions Builder Name (yBuilderSearch/GridDalaRequest?Bui!derSearchGrid-sort=BuilderNami
Example Company (/OrganizationProfi!e/Builder?buitderld=f408ccf5-731b-e511-8087

V B(/BuilderConsole/Create7builder=f408ccf5-731b-e511-B087-005056b7097a)
005056b7097a)
1258520777 Alberta Ltd (/OrganizationProfile/Builder?builderld=29009072-fd23-e511

* Ei (/BuildarConsole/Create?bullder=29009072-fd23-e511-80B7-005056b7097a)
005056b7097a)
B(/BuilderConsole/Create7builder=4b04G682-9825-6511-8087-005056b7097a) Noir Owner (150B 13336810) (/OrganizationProfile/Builder?builderld=4bQ46682-9825

[3{/AutharizatianExemption/Create?builder^4ba466B2-9825-e511-80a7-005056b70973) 8087-005056b7097a)
Ei (/BullderConsale/Create?builder=82d68307-Ocf4-e411-9aa4-005056b7G97a) Gengis Khan (15OB12530968) (/OrganizationProl1le/Builder7builderld=82d68307-0cf'

3(/AiJthorizatianExemption/Creats?builder=82d6B307-OcW-e41t-9aa4-005056b7a97a) 9aa4-005056b7097a)
Joey Tomatoe (/OrganizationProfile/Builder?builderld=12992c61-a1f5-e411-9aa4-

Ei (/BuilderConsDle/Creata?builden:12992c61-a1f5-e411-9aa4-bQ5056b7097a)
005056b7097a)
Builder WK0001 (/OrganizationProfile/Builder?builderld=e1 (8a3a4-b6f5-e411-9aa4-

✓ Ci (/BuilderConsole/Create?buildep=e1f8a3a4-b6f5-e411-9aa4-005056b7097a)
005056b7097a)
Ei (/BuilderConsole/Creale?builder=91 bc00ab-b7!5-e411-9aa4-005a56b7C97a)
"1 Carl Klein (150B12836255) {/OrganizationProfile/Builder?builderld=91bcOOab-b7f5-e‘
0{/AuthorizationExemption/Create?builder=91bcOOab-b7f5-c411~9aa4-005056b7097a) 005056b7097a)
WK Test Builder (/OrganizationProfile/Builder?buitdertd=a188994d-b9f5-e411-9aa4-

Ei pBuilderConsole/Create?builderâ188994d-b9f5-c411-9aa4-005056b7097a}
0O5056b7097a)
Leeroy Jenkins Inc. (/OrganizationProfile/Builder?builderld=e19bbed9-b9f5-e411-9aa

Ei (/BuilderCon5ole/Create?huilder=e19bbed9-b9f5-c411-9aa4-flQ505Gb7097a)
v ! 005056b7097a)
Middle Name Ltd. (/OrganizalionProfile/Builder?bui!derld=af6c1e12-bff5-e41 l-9 a a 4 -

Cl (/BuilderConsole/Create?bui|der=af6c1 e l 2-bff5-e41 1-9aa4-005056b7097a)
-I 005056b7097a)
1 - 10 of 151 items
New Hom e Buyer Protection Office


Page No.00247
10 1 5 5 - 102 Street
Edmonton, AB T5J 4L4 Canada
ES HomeWarranty.inqulries@gov.ab.ca (mailto:HomeWarranty.inquiries@gov.ab.ca)
Q w w w .hom ewarranty.alberta.ca(http://homewarranty.alberta.ca/)
1.866.421.6929
(http://alberta.ca/)
Government

Page No.00248
New Home Buyer Protection System
(/MinistryConsole)
Current User: NHBPS Test Staff 1
Builder Profile
Details and Addresses Primary Contact Other Contacts
Legal N am e#
Example Company
Com pany T y p e #
Corporation ▼
Builder T y p e #
a Residential Owner
Doing B u sin e ss A s
Doing Business As
Phone (999) 9 9 9 -9 9 9 9 #
(780) 234-1213
Fax (999) 999-9999
F ax
Website
Website
Physical Address
Address Line 1 #
1234 56 Street
Address Line 2
AHrirpss I inp 9 Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00249
City#
Edmonton
P r o v in c e #
Alberta ▼
p o s ta l C o d e A9A 9 A 9#
131 313
Mailing Address
Physical & mailing addresses are: - the sa m e different
Save Cancel Back to Search... (/BuilderSearch)
New Home Buyer Protection Office

10155 - 102 Street
Edmonton, AB T5 J 4L4 Canada
S HomeWarranty.inquiries@gov.ab.ca (mailto:HomeWarranty.inquiries@gov.ab.ca)
© www.homewarranty.alberta.ca(http://homewarranty.alberta.ca/)
V. 1.866.421.6929

Page No.00250
Government

Page No.00251
(/MinistryConsole)
Builder Profile
F irs t N a m e #
John
M id d le N am e
Middle Name
Last N a m e #
Doe
E m ail A d d r e s s #
uat.johndoe@maiiinator.com
P h o n e (999) 9 9 9 - 9 9 9 9 #
(780) 662-6222
C e l l (9 9 9 )9 99 -9 9 9 9
Cell
F a x (9 9 9 )9 9 9 -9 9 9 9
Fax
Save Cancel

Page No.00252
10155- 102 Street
0 www.homewarranty.alberta.ca(http://homewarranty.alberta.ca/)
V. 1.866.421.6929
Government

Page No.00253
(/MinistryConsole)
Builder Profile
Add New
First Name Last Name Email Phone Contact Type Options
(780) 662 /
John Doe uat.johndoe@mailinator.com Person In Control
6222 X
(780) 662 Person of

John Doe uat.johndoe@mailinator.com /
6222 Authority
1 - 2 of 2 items

10155 - 102 Street
Edmonton, AB T5 J 4L4 Canada
SB HomeWarranty.inquiries@gov.ab.ca (mailto:HomeWarranty.inquiries@gov.ab.ca)
t - 1.866.421.6929
Government

Page No.00254
N ew Hom e B uyer Protection System
(/MinistryConsole)
Builder Profile
Details and Addresses Account Owner
Builder
Noir Owner (150B13336810)
Builder T y p e#
Residential « Owner
Physical Address
Address Line 1#
235345435
Address Line 2
Address Line 2
C ity #
Jun
Province#
Alberta ▼
Postal Code A9A 9 A 9 #
T7U 9J0
Mailing Address
Page No.00255
Physical & mailing addresses are: the sam e different
Save Cancel Back to Search... (/BuilderSearch)

16th Floor, Com m erce Place
10155- 102 Street
Edmonton, AB T 5 J 4L4 Canada
5S HomeW arranty.inquiries@ gov.ab.ca (mailto:HomeW arranty.inquiries@gov.ab.ca)
@ www.hom ewarranty.alberta.ca(http://homewarranty.alberta.ca/)
V. 1.866.421.6929
Government

Page No.00256
(/MinistryConsole)
Builder Profile
First Name#
Noir
Middle Name
Middle Name
Last Name#
Owner
Email Address#
ob1 @mailinator.com
Phone (999) 9 9 9 - 9 9 9 9 #
(780) 690-8905 ext 8
Cell (999) 9 9 9 -9 9 9 9
Cel!
F a x (999) 9 9 9 -9 9 9 9
Fax
Save Cancel

Page No.00257
10155 - 102 Street
V. 1.866.421.6929
Government

Page No.00258
Current User: NHBPS Test„Staff 1
Builder Search
■/ Residential Builders
■f Owner Builders
Search By:
B uilder Name:
Builder Name
NHBPO Builder ID:
NHBPO Builder ID
WP Builder ID:
WP Builder ID
Q Search
Actions Builder Name (/BuilderSearch/GridDataRequest?BuilderSearchGrid-sort=BuilderNami
Example Company (/OrganizationProfile/Builder?builderld=f408ccf5-731b-e511-8087-

□ Ei {/BuilderConsole/Create?builder=f408ccf5-731 b-e511-8087-005056b7097a)
005056b7097a)
1258520777 Alberta Ltd (/OrganizationProfile/Builder7builderld=29Q09072-fd23-e511

Ei (/BuilderConsolB/Create7builder=29009072-fd23-e511-8087-005056b7097a)
005056b7097a)
*1 Bt/BuilderConsole/Create7builder=4b04BS82-9825-e511-8037-005a56b7097a)
@(/AuthorizationExemption/Create?builder=4b046682-9825-e511-8087-QG5056b7097a)
Noir Owner (15OB13336810) (/QrganizationProfile/Builder?builderld=4b046682-9825
8067-005056b7097a}
Ci (/BulldsrCcmsole/Creata1lbullder=82d683p7-Ocf4-e411-9aa4-005056b?097a) Gengis Khan (15OB12530968) (/OrganizationProfile/Builder?buildertd=82d68307-0cf‘

(3 (/AutharizaiionExemption/CrBate?builder=B2d683a7-0cf4-e411-9aa4-005056b7097a) 9aa4-005056b7097a)
Joey Tomatoe (/OrganizationProfile/Builder?builder!d=12992c61-a1f5-e411-9aa4-

FI Ei (/BuilderConsole/Create?builder=12992c61-a1f5-€4H-9aa4-005056b7C97a)
005056b7097a)
Builder WK0001 {/OrganizationPrafile/Builder?builderld=e1f8a3a4-b6f5-e411-9aa4-

vI Ei (/BuilderConsole/Creale?builder=e1f8a3a4*b6f5-e411’9aa4-Q05056b7097a)
005056b7097a)
'll S(/BuilderConsole/Create?buildem91bc00ab-b7t5-e411-9aa4-0a5056b7097a)
0 (/AuthorizationExernpticm/Create?builder=91bc00ab-b7f5-e411-9aa4-0{)5056b7097a)
Carl Klein (150B12836255) (/OrganizationProfile/Builder?builderld=91 bc00ab-b7f5-e-
005056b7097a)
WK Test Builder (/OrganizationProfile/Builder?builderld=a188994d-b9f5-e411-9aa4-

F B (/Bui!derConsolefCreale?bui!der=a183994d-b9f5-e411-9aa4-005056b7097a)
005056b7097a)
Leeroy Jenkins Inc. (/OrganizationProlile/Builder?builderld=e19bbed9-b9f5-e411-9aa

v Ei (/Bui]derConsole/Create?buiJder=e19bbed9-b9f5-e411-9aa4-005056b7097a)
005056b7097a)
Middle Name Ltd. (/OrganizationProfile/Builder?builderld=af6c1e12-bff5-e411-9aa4-

r | Ei(/BuilderConsole/CreaLe?builder=af6c1e12-bfT5-e411-9aa4-005056b7097a)
005056b7097a)
1 - 10 of 151 items


Page No.00259
1 0 155-1Q2 Street
© www.hom ewarranty.alberta.ca(http://homewarranty.alberta.ca/)
1.866.421.6929
Government

Page No.00260
B u ild e r N am e: Exampie Company
New Home Buye
P rim a ry C o n ta c t: John Doe
C u rre n t U se r. N H S P S T e s t^ S ta ff t
Monte Builder Search P h o n e N um b er: (780) £62-6222
N H B P O B u ild e r ID: 15RB17649969
Echelon Progressive Heme Warrant;

Builder Search W a rran ty P ro v id e r;
Search For (pick at least or W P B u ild e r ID: 11111
+ R e sid en tia l S u lk le rs V a lid a tio n S ta tu s : validation Approved

•f Ow ner Bu ilders
Search By D ate S u b m itte d : 11/13/201$
B u ild e r N am e: D ate C o m p le te d : 11/13/2015
SUikJet N am e
V a lid a tio n ID: 153V1117295
N H B P O B u ild e r ID:
1 N H 9 P O Sunder ID
0 Close
| WP auttaet iD
Q. Search
A ction s B u lkier N am e ® N H B P O S o lder Id ® P rim ary Contact ® Pho ne
□ E xa m p le C o m p a n y 1 5 R B 1 764 9 96 9 Jo h n D o* {7 W ) 6 6 2 -6 2 2 2
□ 125&52D77? A lberta L id 1 5 R B IB 7 3 8 2 4 3 P rim a ry fn l Prim ary In (7 8 0 ) 9 9 9 -6 6 6 6
EDO ' Noir O w ner i1 5 O B t3 3 3 6 S 1 0 J 1 5 Q B 1 3336810 Ncir O w n e r (7 8 0) 6 9 0 -8 9 0 5 e xl 8
□J G e n g is K h a n '*1 5 O B 1 2 5 3 0 9 6 S ) 150512530966 G e n g is K han (7SG ) 555 -55 5 5
Jo e y T om atoe 1 5 R B 1 2837127 Jo e y Tom atoe

m n (7 8 0) 2 3 4 -3 2 2 3 ext 4
□ . Bunder WKOOQ1 1 5 R B 1 2531074 W ilhelm Kart (7 8 0 ) 5 56 -88 8 8
H H B i C at! K le in {1 5 0 8 1 2 6 3 6 2 5 5 } 1 5 Q B 12936255 C a rl Klein (7 8 0 ) 5 55 -55 5 5
fflB®.

Page No.00261
N ew H om e B uyer Protection System
(/MinistryConsole)
New Home Registration

Application Information
Application ID
Status
f
Draft
Application Date
Builder Information
Builder Name
. — —— »■
Example Company
User Name
t
Phone
Email
Building Information
Page No.00262
Building ID
Project Name
Building Name
Construction Type
New Construction T
Building Type
Single-Family Detached T
Building Sub-type
Site-Built ▼
Municipality
□ This building is a condominium or part of a condominium development.
□ This building will have an additional 2 years building envelope coverage.
Warranty
Warranty Provider
Echelon Progressive Home Warrant) ▼
Building Location
Building L o ca tio n
Units
Select Unit Number Location Line Policy Number Registration Unit ID

Page No.00263
Unit
□
Location
Save and Submit Save As Draft De-Enroll Selected Units Cancel Selected Units
Create Assessment (/Assessment/Create/5d 11 eeb5-f6d 1-4f50-8a60-a0d8bb6415cb)
Cancel

10155 - 102 Street
H HomeWarranty.inquiries@gov.ab.ca (mailto:HomeWarranty.inquiries@gov.ab.ca)
V. 1.866.421.6929
Government

Page No.00264
Page No.00265
(/MinistryConsole)
Application for Owner Builder Authorization

Part 1
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Contractor Information
Part 5
Verification
Primary Applicant
Primary Applicant Details Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00266
First Name*
Noir
Middle Name*
Middle Name
Last Name*
t 1 ■ ' ... . . . »
Owner
Email Address* (primary method of contact)
ob1 @mailinator.com
Phone*
. ......... ......... .
(780) 690-8905 ext 8
Cell
/ ......... S
Cell Phone
Fax
r 11 1 1 ■■ ■>
Fax
Driver's License Number*

tam" '* 11 ■■■■' . ■■ . . . . s
Drivers License
Date of Birth (YYYY-MM-DD)*
Questionnaire
1. I am applying for an authorization to build a single detached house without warranty.
O Yes
O No
2. I intend to personally occupy the new home as my primary residence for:
O less than 10 years
O 10 years or more
3. I intend to personally engage in, arrange for or manage all or substantially all of the
Page No.00267
construction of the proposed new home.
O Yes
O No
4. I intend to hire a builder, general contractor, project manager or construction manager
to build the proposed new home.
O Yes
ONo
5. I understand that I am required to and will update the registry to include the following
information:
a. the names of and contact information for all the subcontractors who were involved in
building the new home, if different from those who were listed on application;
b. the date when I first occupy the new home.
O Yes
ONo
6. I understand that I am required to obtain warranty coverage on the new home, or
obtain an exemption from the Registrar from that requirement, if I wish to sell or offer
to sell the new home within 10 years of the occupancy date.
O Yes
O No
7. I understand that warranty providers may:
a. refuse to provide coverage under a home warranty insurance contract,
b. determine the cost of coverage under a home warranty insurance contract based on a risk
assessment and
c. to request detailed information about the new home and the construction process from
me/us.
O Yes
O No
8. I have the following ownership interest in the land where the new home is to be built:
□ An interest in fee simple
□ A life interest
□ At least a half interest in tenancy in common
□ Share with one other person - joint tenancy
□ A registered interest under a lease with a term of at least 15 years
□ An unregistered lease
□ Option to purchase
□ Purchase and sale agreement
□ Other

Page No.00268
9. The interested referred to in question 8 is:
O Solely in my individual name
O Partly in my individual name and partly in the name of the corporation or one or more
other individuals
O Solely in the name of a corporation
O Solely in the names of other persons
10. I intend to use the new home:
□ The new home will be my primary residence
□ The new home will be a secondary residence or my personal use, such as recreational,
property
□ The new home will be a rental investment property
□ I intend to sell the new home within the next 10 years
11. This is the first home I or anyone ordinarily resident with me has built as an owner
builder.
O Yes
ONo
12. I have made a false or misleading statement in a previous application for an
authorization.
O Yes
O No
13. I have been subject to the following actions under the N e w H o m e B u y e r P ro te c tio n
A c t:
□ Compliance Order
□ Monetary Penalty
□ Conviction of an offence under the New Home Buyer Protection Act
□ None of Above
14. I have not been ordinarily resident in a new home for which another person was
issued owner builder an authorization in the previous 3 years
O Yes
ONo
15. Ido not meet all of the criteria for an owner; builder, and an explanation is attached to
this document.
O Yes
O No
Page No.00269
A Please Note: Your Application for Owner Builder Authorization will not be considered
complete until the original downloadable completed application, including the completed
sworn Affidavit of Execution, has been received by the New Home Buyer Protection Office.
M Cancel Changes Next >
Submission Instructions
The Submit button above sends the online version of your application to the NHBPO, you will then view your
fee summary page where you can confirm your fees and download the form so you may complete your
application.
Payment Information
You may pay online or off line, please Submit and proceed to the Fee Summary page.
THE FEE FOR APPLICATION FOR OW NER BUILDER AUTHORIZATION IS NON REFU N DA B LE
Privacy Statement
The collection of personal information is necessary to support the New Home Buyer Protection Program. The
collection is authorized under section 33(c) of the Alberta Freedom of Information and Protection of
Privacy(FOIP) Act and will be managed in accordance with the privacy provisions in the A ct If you have
questions regarding the collection of your personal information, please send your inquiry to the New Home
Buyer Protection Office,16th Floor,Commerce Place, 10155 - 102nd Street, Edmonton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

10155 -1 02 Street
Q www.homewarranty.alberta.ca(http://homewarranty.alberta.ca/)
V. 1.866.421.6929
Governm ent
Page No.00270
(/MinistryConsole)

P a rti
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
Required fields are marked with
Applicants + Add Co-Applicant
A co-applicant is anyone who share the title of the proposed property. You
must identify all co-applicants.
Primary Applicant Co-Applicant
Co-Applicant1 Details — Remove Co-Applicant

Alberta Municipal A fairs Information Request 2015-R-0088
Page No.00271
j
First Name*
t ■ 1 1 " '■ t
Legal Given Name
Middle Name*
/ ■.■■■ ■■■■■■ 111 ............. ......H
Middle Name
Last Name*
...... '■■■ 1 *
Last Name

t mat...... ..... . 111 \
Email Address
Phone*
/—1 1 ■■ 1.... . .....
Phone
Cell
Cell Phone
Fax
1■ ■ i ■' ■ ..................... ■■ ■■ ■■■ i ■■ »
Fax
Driver's License Numbei*
Drivers License
Questionnaire
O Yes
ONo
O 10 years or more
Page No.00272
O Y es
ONo
O Yes
ONo
information:
O Yes
ONo
O Yes
O No
assessment and
me/us.
O Yes
O No
□ A life interest
□ Other

Page No.00273
1_________________________________________ ^

other individuals

property
builder.
O Yes
ONo
authorization.
O Yes
ONo
A c t:
□ None of Above
O Yes
ONo
15. Ido not meet all of the criteria for an owner builder, and an explanation is attached to
this document.
O Yes
O No
Page No.00274
DIDCancel Changes Next >
application.
Paym ent Information

THE FEE FOR APPLICATION FOR OWNER BUILDER AUTHORIZATION IS NON REFUNDABLE
Privacy Statement
The collection of personal Information is necessary to support the New Home Buyer Protection Program. The
Privacy(FOIP) Act and will be managed in accordance with the privacy provisions in the Act. If you have
telephone to 1-866-421-6929.

Governm ent of Alberta
10155- 102 Street
B HomeWarranty.inquiries@gov.ab.ca (mailto:HomeWarranty.inquiries@gov.ab.ca)
V. 1.866.421.6929
Government
Page No.00275
(/MinistryConsole)

P a rti
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
Required fields are marked with ♦ .
Physical Address
Address Line 1*
Address Line 1
Address Line 2
Address Line 2
City*
City Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00276
Province
Select Province... ▼
Postal Code*
Postal Code
Current home & mailing addresses are: © the same o different
Mailing Address
< Previous ffi Cancel Changes Next >
application.

Privacy Statement
telephone to 1-866-421-6929.

Page No.00277
10155 - 102 Street
V. 1.866.421.6929
Governm ent

Page No.00278
(/MinistryConsole)

Part 1
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
New Home Location
You must provide at least one type of location description. Civic/Rural Address, Lot-Block-Plan, or
ATS
Select address type: ® Civic Address o Rural Address
Civic Address
Building ID:
Page No.00279
Unit Number
Unit No.
LINC
LINC
Street Number
Street No
Street Name
Street Name
Street Type
Select Street Type... ▼
Street Direction
Select Direction... T
Municipality
Select Municipality... T
Postal Code
POSTAL CODE
Lot-Block-Plan
Add Lot/Block/Plan (/AuthorizationExemption/Create?builder=4b046682-9825-e511-8087-
005056b7097a&lbpGrid-mode=insert)
Lot Block Plan
Ordinarily Resident Adults

Page No.00280
An Ordinarily Resident Adult is anyone over 18 years of age residing in the
home. You must identify all ordinarily resident adults.
Add Ordinarily Resident Adult (/AuthorizationExemption/Create?builder=4b046682-9825-

e511-8087-005056b7097a&ResidentsGrid~mode=insert)
Legal Giv... Middle N... Last Nam... Phone (/A... Email {/A... Date of Bi...
0 No items to display
K Previous H Cancel Changes Next >
Submission instructions
application.
Payment Information
You may pay online or offline, please Submltand proceed to the Fee Summary page.
Privacy Statement
Buyer Protection Office,16th Floor,Commerce Place, 10155 - 1 02nd Street, Edmonton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

Page No.00281
10155- 102 Street
1.866.421.6929
Government

Page No.00282
N ew H om e B uyer Protection System
(/MinistryConsole)

P a rti
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
Subcontractors who will be involved in building new the home.
Add new Contractor (/AuthorizationExemption/Create?builder=4b046682-9825-e511-

8087-005056b7097a&ContractorGrid-mode=insert)
Trade Business Name Address Phone

Page No.00283
< Previous DmCancel Changes Next >
application.
Payment Information
You may pay online or offline, please Submit and proceed to the Fee Summary page.
Privacy Statement
Buyer Protection Office,16th Floor,Commerce Place, 10155' - 102nd Street, Edmonton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

10155 - 102 Street
1.866.421.6929
Government
Page No.00284
(/MinistryConsole)

Part 1
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
Required fields are marked with # .
Applicant(s)
Date
of Driver's Questionnaire
First Name Last Name Birth License Phone Cell Fax Email Complete?
Noir Owner (780) ob1 @mailinator.com X

690
8905
ext 8
Current Home
Page No.00285
Physical Address
Mailing Address

First Name Last Name Date of Birth Phone Email
l
New Home
Unit Number
LINC
Civic Address
»
, Alberta
Lot/Block/Plan
Contractors)
Trade Business Name Registered Address Phone
Warnings
• Applicant (Part 1) Drivers License is missing
• Questionaire (Part 1) is not complete for: Noir Owner. Each applicant MUST complete the
questionaire.
• Applicant (Part 1) Noir Owner DoB should be in yYYY-MM-DD format
• Applicant (Part 1) Noir Owner is missing date of birth
• Applicant (Part 1) First Name is missing
• Applicant (Part 1) Last Name is missing
• Phone number"" for (Part 1) is missing or not a valid phone number
• Email"" for (Part 1) is missing or not a valid Email
• Questionaire (Part 1) is not complete for:. Each [applicant MUST complete the questionaire.
• Applicant (Part 1) DoB should be in YYYY-MM-DD format
• Applicant (Part 1) is missing date of birth
• Current Address (Part 2) Address Line 1 is missing Alberta Municipal Affairs Information Request 2015-R-0088
Page No.00286
• Current Address (Part 2) City is missing
• Current Address (Part 2) Province is missing
• Current Address (Part 2) Postal Code is missing
• New Home (Part 3) Municipality is missing
• New Home Location (Part 3) must have at least one of the legal descriptiosn is required:
Lot/Block/Plan, ATS Standard, or ATS Non-Standard
A Please Note: Your Application for Owner Builder Authorization will not be considered complete
until the original downloadable completed application, including the completed sworn Affidavit of
Execution, has been received by the New Home Buyer Protection Office.
< Previous M Cancel Changes
The Submit button above sends the online version of your application to the NHBPO.you will then view your fee
summary page where you can confirm your fees and download the form so you may complete your application.
Payment Information
Privacy Statement
collection is authorized under section 33(c) of the Aiberta Freedom of Information and Protection of Privacy(FOIP) Act
and will be managed in accordance with the privacy provisions in the Act. If you have questions regarding the
collection of your personal information, please send your inquiry to the New Home Buyer Protection Office,16th
Floor.Commerce Place, 10155 - 102nd Street, Edmonton, AB, T5J 4L4 or telephone to 1-866-421-6929.

10155-102 Street
O www.homewarranty.alberta.ca(http://homewarranty.alberta.ca/)
Page No.00287
^ 4{bwkxKM Government

Page No.00288
Current User; NHBPS Test_Staff 1
NHBPO Staff Console

All Applications Awaiting Payment Awaiting Approval Commencement Occupancy Assessment Builders
G Reset Filter
Actions Application ID (/MinistryConsoleGrid/GetAIIRegistratians7MinistryRegGrid-sort=RegistrationNo
f t (/O cc u p a n cy ? id = b c2 1 1 6 2 7 -8 c9 f-e 5 1 1 -8 0 cd -0 0 5 0 5 6 a f7 e 8 3 )
f 15RE1127359 (/BuilderConsole/LoadRegistration?appNumber=15RE1127359)
pS| (/P d r/P rin tA p p 7id = 1 5 R E 1 1 2 73 5 9 ) £■ (/Pdf/PrintCert?id=15 R E 1 1 2 7 3 5 9 )
A (/ O c c u p a n c y ? td = 8 3 a e 3 4 3 5 -f3 9 d -e 5 1 1 -8 0 c b -0 0 5 0 5 6 a f7 e 8 3 )
y 15RE1127051 (/BuilderConsole/LoadRegistration?appNumber=15RE1127051)
& (/P d t/P rin tA p p ? id = 1 5 R E 1 1 2 7 0 5 1 ) Js l(/P d f/ P rin tC e rt? id = 1 5 R E 1 1270 5 1 )
$ (/M in istryC o n so le /P a ym e n l?id = 9 7cb 3c4 2-4 19 9 -e 5 1 1 -80 cb -0 0 5 0 5 6 a f7 e B 3 )

f 15RE1126868 (/BuilderConsole/LoadRegistration7appNumber=15RE1126868)
l? l (/Fd f/P rin tA p p ?id = 1 5 R E 1 1 2 6 3 6 8 )
ft(/O c c u p a n c y ? id = 4 7 9 0 9 b 4 0 -2 a 9 9 -e 5 1 1 -8 0 c d -0 0 5 D 5 6 a f7 e 8 3 )
f 15RE1126516 (/BuildBrConsole/LoadRegistration?appNumber=15RE1126516)
© (/Pdf/Pri a tA p p 7 id = 1 5 R E 1 1 2 6 5 1 6 ) S ( 4 W r in t C e r t ? id = 1 5 R E 112 6 5 1 6 )
A (A D ccu p a n cy ? id = 7 c8 6 d 6 2 1 -2 9 9 9 -e 5 1 1 -8 0 cb -Q 0 5 0 5 6 a f7 e 8 3 )
S 15RE1126287 (/BuilderConsole/LoadRegistration7appNumber=15RE1126287)
© (/P df/Pn 'n tA pp ?id = 1 5 RE1 1 2 6 2 8 7 ) |S| (/P d f/P rin tC e rt? id = t5 R E 1 1 2 6 2 B 7 ) |
f t(/ O c c u p a n c y 7 ld a fs6 7 t6 fd -5 9 9 5 -e 5 1 1 -8 0 cb -0 0 5 a 5 6 a f7 e B 3 )
f 15RE1126013 (/BuilderConsole/l_oadRegistration?appNumber=15RE1126013)
p& (/P d f/P rin tA p p 7 id -1 5 R E 1 1 2 6 0 1 3 ) S (/P d f/P rin lC e rt7 id = 1 5 R E 1 1 2 6 0 1 3 )
S (/ M lrlstry C o n so le /P a y m e n t? id = 8 5 b d 5 9 5 3 -e 3 8 3 -e 5 1 1-8 0 c 9 -0 0 5 0 5 6 a f7 a 8 3 )
✓ 15RE1125522 (/BuilderConsole/LoadRegistration?appNumber=15RE1125522}
^ (/P d f/P rin tA p p ? id = 1 5 R E 112 5 5 2 2 )
S (/Fdf/PrintA pp7ld=15 R E 1 12 5 4 1 8 ) ✓ 15RE1125416 (/BuilderConsofe/LoadRegistration?appNumber=15RE1125418)
. * (/A p p ro va !/A p p ro vB ?id = 4 d 78 c97 5 -b 0 8 1 -« 51 1 -80 c9 -0 0 5 0 5 6 af7 e8 3 )

✓ 15RE1125259 (/BuilderConsole/LoadRegistration?appNumber=15RE1125259)
f i (/P d f/P rin tA p p ? id = 1 5 R E 1 1 2 5 2 5 9 )
f t {/O cc u p a n c y ? id = 8 9 b 2 9 b 2 7 -4 3 1 0 -e 5 1 1 -9 a a 4 -00 5 0 56 b 7 0 9 7 a )
f 15RE1120070 {/Bui!derConsole/LoadRegistration?appNumber=15RE1120070)
|S|(/Pdf/PrintApp7id = 1 5 R E 1 1 2 00 7 0 ) |S| (/P d f/P rin tC e rt7 id = 1 5 R E 1 12 0 0 7 0 )
p1~[ 2 3 4 5 1 - 10 of 50 items

10 155- 102 Street
H HomeWarranty.inquiries@gov,ab,ca (maitto:HomeWarranty.inquiries@gov.ab.ca)
Q www.hom ewarranty.alberta.ca(http://homewarranly.alberta.ca/)
1.866.421.6929
G .ernn;ent (h ttP -//3 lb e r t3 .C a /)

Page No.00289
(/MinistryConsole)
Application for Rental Exemption

15RE1127359
Part 1
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Applicants Add Co-Applicant
A co-applicant is anyone who shares the title of the proposed property. You
Primary Applicant
Primary Applicant Details

Page No.00290
Name on Title*
Kate - mulit unit test
A uthorized Person*
t ■ ......... ■■ ■
Kate
Email A ddress*
gham@gmail.com
Phone*
(780)594-2321
Physical Address
Address Line 1*
1 in the Peanut Gallery
Address Line 2
Address Line 2
City*
Lethbridge
Province
Alberta ▼
Postal Code*
T6Y 7I8
Mailing Address
Current physical & mailing addresses are: <§> Same o Different
Agreement*
I am requesting a rental exemption under Section 3 of the New Home Buyer Protection Act. I agree
to the following terms and conditions by clicking the submit button.
Page No.00291
/ j I understand that Pursuant to Section 3.1(8) of the Act, when this designation is registered on the
certificate of title to the Lands, the lands may not be:
a. Sold, made subject to an agreement for sale or otherwise disposed of, unless it is sold to a
person referred to in Section 3.1(3) of the Act.
b. Included in a condominium plan or a proposed condominium plan, or
c. Subdivided in any other manner, during the protection period applicable to the multiple family
dwelling(s) under Section 1.1 of the Act without the written permission of the Registry.
v I agree and understand that the Registrar will register a Caveat against the rental property for
the duration of the protection period. Upon expiry of the protection period, the Registrar will
discharge the Caveat from the rental property.
* I must provide to the Registrar the earlier of the date an accredited agency, accredited
municipality or accredited regional services commission grants permission to occupy the multiple
family dwelling, and if permission described in the above clause is not granted, the date the
multiple family dwelling is first occupied.
Download Certificate Notes H Delete Application H Cancel Application
H Cancel Changes Next ^
application.
To complete your application, a printed copy of the application signed by each applicant must be sent to the
New Home Buyer Protection Office, 16th Floor, Commerce Place, 10155 - 102nd Street, Edmonton, AB, T5J
4L4.
Payment Information
THE FEE FOR APPLICATION FOR RENTAL EXEMPTIONS IS NON REFUNDABLE
Privacy Statement
Privacy(FOlP) Act and will be managed in accordance with the privacy provisions in the Act. If you have
telephone to 1-866-421-6929.

Page No.00292
10155 - 102 Street
E5 HomeWarranty.inquiries@gov.ab.ca (mailto:HomeWarranty.inquiries@gov.ab.ca)
V. 1.866.421.6929
Government

Page No.00293
(/MinistryConsole)
Current User: NHBPS Test_S taff 1

15RE1127359
Required fields are marked with #■.
P a rti
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Primary Applicant Co-Appiicant

Page No.00294
Name on Title*
Name on Title
Authorized Person*
Authorized Person
Email Address*
t t,mi 1
name@sample.com
Phone*
Phone
Physical Address
Address Line 1*
Address Line 1
Address Line 2
Address Line 2
City*
City
Province
Select Province... T
Postal Code*
Postal Code
Mailing Address
Current physical & mailing addresses are: <8> Same o Different
Agreement*
Page No.00295
I understand that Pursuant to Section 3.1(8) of the Act, when this designation is registered on the
I agree and understand that the Registrar will register a Caveat against the rental property for
I must provide to the Registrar the earlier of the date an accredited agency, accredited
JL Download Certificate Notes HIDDelete Application H Cancel Application
d Cancel Changes Next ^
application.
To complete your application, a printed copy ofthe application signed by each applicant must be sentto the
New Home Buyer Protection Office, 16th Floor, Commerce Place, 101 5 5-1 02nd Street, Edmonton, AB, T5J
4L4.

Privacy Statem ent

collection is authorized under section 33(c) ofthe Alberta Freedom of Information and Protection of
Privacy(FOiP) Act and will be managed in accordance with the privacy provisions in the Act. If you have
Buyer Protection Office,16th Floor,Commerce Place, 1 0 1 5 5 -1 02nd Street, Edmonton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

Page No.00296
10155- 102 Street
V. 1.866.421.6929
Government

Page No.00297
(/MinistryConsole)
Current U se r NHBPS Test_Staff 1

15RE1127359
Part 1
Appticant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Legal Business Name*

r "
More Noir
C ontact Person Legal Name*

f " m" " — « i K
Plus Four
Phone Number*
(780) 243-3213
Email Address

Page No.00298
noir.plusfour@mailinator.com
K Previous ^ Download Certificate Notes 110 Delete Application
® Cancel Application ffi Cancel Changes Next >
application.
4L4.
Payment Information
Privacy Statement
telephone to 1-866-421-6929.

10155 - 102 Street
V. 1.866.421.6929

Page No.00299
Govern,,on; (http://alberta.ca/)

Page No.00300
(/MinistryConsole)
Application for Rental Exemption 15RE1127359

P a rti
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Building ID
15BD1207877
Project Name
Project Name
Building Name
Building Name
Construction Type
New Construction ▼

Page No.00301
Building Type
Multi-Family ▼
Building Sub-type
Rental ▼
M unicipality
DeBolt ▼
Number o f Buildings
Total Number o f Units (all buildings)
650
Details
Building Address
You must provide at least one method of identifying the location of rental property
LINC (separate m ultiple LINC's with a comma)
4564327958
What type of address best describes the building location?: ® C iv ic O| Rural
Add Address (/RentalExemption/Load/15RE1127359?addrGrid-mode=insert)
Street Number Street Name Street Suffix Street Type Street Direction Postal Code
> > >'' > t » t , ....» r ........ ......... •> t \
1 Peanut Croissant T6Y 7I8
Lot/Block/Plan
Add Lot/Block/Plan (/RentalExemption/Load/15RE1127359?lbpGrid-mode=insert)

Page No.00302
Lot Block Plan
5 6 1234454
Legal Location Type

What type of address best describes the building location?: ATS (Alberta Tow nship System ) Standard o
A T S (A lberta Tow nship System ) Non-standard
Add ATS Standard (/RentalExemption/Load/15RE1127359?atsGrid-mode=insert)
Legal Subdivision Quarter Section Township Range Meridian
K Previous at Download Certificate Notes P Delete Application
11 Cancel Application H Cancel Changes Next y
The Submit button above sends the online version of your application to the NHBPO, you will then view your fee
summary page where you can confirm your fees and download the form so you may complete your application.
To complete your application, a printed copy of the application signed by each applicant must be sent to the New
Home Buyer Protection Office, 16th Floor, Commerce Place, 10155- 102nd Street, Edmonton, AB, T5J 4L4.
Payment Information
You may pay online oroffline, please Submit and proceed to the Fee Summary page.
Privacy Statement
collection is authorized under section 33(c) of the Alberta Freedom of Information and Protection of Privacy(FOiP)
Act and will be managed in accordance with the privacy provisions in the Act. If you have questions regarding the
collection of your personal information, please send your inquiry to the New Home Buyer Protection Office,16th
Floor,Commerce Place, 10155 - 102nd Street, Edmonton, AB, T5J 4L4 or telephone to 1-866-421-6929.


Page No.00303
10155 - 102 Street
V. 1.866.421.6929
Government

Page No.00304
(/MinistryConsole)

15RE1127359
Required fields are marked with $ .
Part 1
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Applicant(s)
A uthorized Agreem ent

Name On Title Person Email Phone Answered
Kate - mulit unit Kate gham@gmail.com (780) 594- ✓

test 2321
Builder

Page No.00305
Legal Business Name
More Noir
Contact Person Legal Name
Plus Four
Phone Number
(780) 243-3213
Email Address
New Building (Building ID :16B D 1214537)
Project:
R ental: 650 Units, 1 Buildings
Municipality: DeBolt
Location of Rental Property
LINC
4564327958
Building Address(s) Lot/Block/Plan(s)

1- Peanut Croissant Lot: 5 Block: 6 Plan 1234454
DeBolt, A B T 6 Y 7 I8
Warnings
• Applicant (Part 1) Name on Title is missing
• Applicant (Part 1) Authorized Person is missing
• Address Line 1 for (Part 1) is missing
• City for (Part 1) is missing
• Postal Code for (Part 1) is missing
• Phone num ber"" for (Part 1) is missing or not a valid phone number
• E m a i l f o r (Part 1) is missing or not a valid Email
• Questions (part 1) not answered for applicant Unknown

Page No.00306
r
K Previous JL Download Certificate Notes ED Delete Application
---------------------------------
EDI Cancel Application M Cancel Changes
application.
4L4.
Payment Information
Privacy Statement
Privacy(FOlP) Act and will be managed in accordance with the privacy provisions in the Act. If you have
questions regarding the collection of your persona! information, please send your inquiry to the New Home
telephone to 1-866-421-6929.

10155 - 102 Street
V. 1.866.421.6929
^/4 t b a r Government

Page No.00307
Current User NHBPS Test_Staff 1
NHBPO Staff Console

G Reset Filter
Actions Application ID (/MinistryConso!eGrid/GetAIIRegistrations?MinistryRegGrid-sort=RegistraiionNo'
$ (/M in istryC o n so |0 /P a ym en t? id = b 63 4 a b 7 7 -47 a 3 -e 5 11 -8 0cf-0 0 50 5 6 af7 e8 3 ) /■ 15RF1166030 (/BuilderConsole/LoadRegistration?appNumber=15RF1166030)
^ $ (/M in islry C o n so le /P a y m e n t? id = a b 0 7 d 1 8 4 -3 2 a 0 -e 5 1 1 -8 0 c d -0 0 5 0 5 6 a f7 e 8 3 ) f 15RF1165081 (/BuilderConsole/LoadRegistration?appNumber=15RF1165081}
$ (/M im stry C o n so le /P ay m e n t?id = 8 e 7 7 3 4 7 3 -3 2 a 0 -e 5 1 1 -8 0 cd -0 0 5 0 5 6 a f7 e 8 3 ) f 15RF1164869 (/BuilderCon5ole/LoadRegistration?appNumber=15RF1164869)
$ (/M in istry C o n so le /P a ym e n t? id = 1 e 1 4 a 8 2 0 -1 b a0 -e 5 1 1 -8 0 cd -0 0 5 0 5 6 a f7 e 8 3 ) /■ 15R F1164686 (/BuilderConsote/LoadRegistration?appNumber=15R F1164686)
$ (/M inistryC onsale/Paym ent?id=eafad3Q 4-1 b a 0 -e 5 1 1 '8 0 cd -0 0 5 Q 5 6 af7 e 8 3 ) ✓ 15RF1164444 (/BuilderCanso[e/LoadRegistration?appNumber=15R F1164444)
$ (/M in istryC o n so le /P a ym e n t?id =3 6 fB e 2 e b * 1 a aO -e 51 1 -8 0 cd -0 05 0 5 6a f7e 8 3 ) f 15RF1164276 (/BuilderConso!e/LoadRegistration?appNumber=15RF1164276)
S (/M in istry C o n so le /P a ym e n t? id = 3 0 3 4 c6 d 3 -1 aa O -e 5 1 1 -8 0 cd -0 0 5 0 5 6 a f7 e 8 3 ) f 15RF1164085 (/BuilderConsole/LoadRegistration?appNumber=15RF1164085}
$ (/M in istryC o n so le /P a ym e n t? id =9 7 cb 3 c4 2 -4 19 9 -e 5 1 1-80 cb -Q 0 5 05 6 a f7 e 83 )

# 15RE1126868 (/BuilderConsole/LoadRegistration?appNumber=15RE1126868)
(/P d f/P rin lA p p ? id = 1 5 R E 1 12 6 8 6 8 )
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S (/M in istry C o n so le /P a ym e n t? (d = 2 7 4 7 aB 8 3 -8 a 9 4 -0 5 1 1 -8 0 c b -0 0 5 0 5 6 a f7 e 8 3 ) /■ 15RF1161317 (/BuilderConsole/LoadRegistration?appNumber=15RF1161317)
1 - 10 of 22 items
i^ j2 3

10 1 5 5 - 102 Street
9 www.hom ewarranty.alberta.ca(http://homewarranty.alberta.cay)
V. 1.866.421.6929
y & ib -e rb C y M g™ , (http://alberta.ca/)

Page No.00308
(/MinistryConsole)
Confirm Paym ent
Registration Number:
15R F1166030
Project:
Jack's Payment Test 12/15/15
Builder:
More Noir
W arranty Provider:
Millennium Insurance Corporation
Paym ent Methods
Paym ent Channel:
Choose... T
A m ount Due:
$95.00
Payment:
Choose... ▼
Notes :

Page No.00309
Amount Paid:
t--------------------------------
$95.00
Reference Number:
El Submit Print (/Pdf/Paymentlnvoice?invoiceNumber=16IV00653150)
0 Cancel (/MinistryConsole)

10155- 102 Street
V. 1.866.421.6929
Government
h & t b fa M

Page No.00310
Current User: NHBPS Tes1_Staff 1
NHBPO Staff Console

£5 Reset Filter
Actions Application ID (/MinistryConsoleGrid/GetAIIRegistra1ions?MinistryRegGrid-sort=RegistrationNo-
^ (/W a rra n ty C o m m e n ce m e n 1 7 id = 9 6 a 7 8 a 1 9 -3 3 a 0 -e 5 1 1 -8 0 cd -0 0 5 0 5 6 a f7 e 6 3 )
y 15R F1165412 (/BuilderConsole/LoadRegistratjon?appNumber=15RF1165412)
& (/P d f/P rin tC e rt? id = 1 5 R F 1 16 5 4 1 2 )
A (/W afTantyCom m encem ent?td = 8 ed 9 3 b9 t3 -3 2 at> -e S1 1 -8 0 cd -0 05 0 5 3a f7e 8 3 )

y 15RF1165215 (/BuilderConsole/LoadRegistration?appNumber=15RF1165215)
f t (/P d (/P rin tC e rt? ld = 1 5 R F 1 1 6 5 2 1 5 )
A (/W a rra n ty C a rT im e n ce m a n t? id = a 6 7 a 1 2 c 3 -3 5 9 9 -e 5 1 1 -8 0 c b -C 0 5 0 5 6 a f7 e 8 3 )
✓ 15RF1163452 (/BuilderConsote/L.oadRegisSration?appNumber=15RF1163452)
f t < /P d f/P rin tC ert?id =1 5 R F1 1 6 34 5 2 )
^ {r W a n a n ty C a m m e n c e m e n t? id = 4 d 2 d 7 2 e 3 -8 0 9 4 -e 5 1 1 -8 0 c b -0 0 5 0 5 6 a f7 e 8 3 )
f t (IP d W =rin tCe rt7 id = 15 R F1 1 6 08 4 7 )
ft (/W arra n tyC o m m en cem e n t? id =7 6 3 b 8 0 cf-d rB 3-e 5 11 -8 0c9 -0 0 5 05 6 at7 e 8 3)

f t (ZPdf/PrintCe rt7 id = 1 5 R F 1 1 5 3 4 2 6 )
A (/W a n a n ty C o m m e n c e m sn t? id = 1 0 0 6 0 a 9 f-7 4 7 e -e 5 1 l-8 0 c 9 -0 3 5 d 5 6 a f7 e 8 3 )

y 15RF1156870 {/BuilderConsole/LoadRegistration?appNumber=15RF1156870)
f t (/Pdf/Pn n tC e ri7 id = 1 5 R F 1 156 B70)
A (/ W a n a n ty C o m m e n c e m e n t? id = 6 6 c 3 b 7 c 1 -0 0 6 d -e 5 1 1 -a c 3 e -0 0 5 0 5 6 b 7 0 9 7 a )
f t (/P d fF rin tC e r1 7 id = 1 5 R F 1 1 5 3 6 3 9 )
A (/W a rra n ty C o m m e n c e m e n t? id -1 6 5 8 6 d 1 f-c 8 6 3 -e 5 1 1 -a c 3 e -0 0 5 0 5 6 b 7 0 9 7 a )

f t (/Pdt/PrintCert?id=15 R F 1 1 5 3 1 5 3 )
^ (rW a rran ty C o m n n e n c0 m en t? id = 1 7 d b c5 d 8 'a 2 6 Q -e 5 1 1 -ac3 e -O O 5 O 5 6 b 7 O 9 7 a)

y 15R F1152746 (/BuilderConsole/LoadRegistration?appNumber=15RF1152746)
f t (/P d f/P rin tC e rt? id = 1 5 R F 1 1 5 2 7 4 6 )
A (/W arrantyCom rnencem erU?itf“ 1 3 cc d 3 4 6 -5 0 5 e -e 5 1 1 -a c3 e -0 D 5 Q 5 6 b 7 D 9 7 a )

y 15RF1151955 (/BuilderConsDie/LoadRegistration?appNumber=15RF1151955)
f t (/P d l/P rin tC e rt? id = 1 5 R F1 1 5 1 9 5 5 )
2 3 4 5 6 7 8 9 10 1 - 10 of 99 items
□

10155- 102 Street
S ! HomeWarranty.inquiries@gov.ab.ca (maiito:HomeWarranty.inquiries@gov.ab.ca)
Q www.homewarranty.alberta.ca (bttpd/homewarranty.alberta.cal)
1.866.421.6929
^ A lb e r t ^ M G ovornn,,,,,' ( h t t P ^ l b e r t a . «
Page No.00311
Current User. NHBPS Test_Staff 1
W a rra n ty C o m m e n c e m e n t
Registration Information
Builder
Mike O'Brian (13O800Q0QQ0)
15RF1165412
Project:
Kate
Unit Commencement
Registration Unit ID Civic Address Policy Number Commencement Date Reported By Reported Date Actions
15RU1249663 22-22-42342343 5983490584 amarbir.randhawa@gov.ab.ca 01/06/2016
0 1 - 1 of 1items
0 Save Cancel

10155-102 Street
0 www.homewarranty.alberla.ca (ht1p://homewarranty.alberta.ca/)
V. 1.866.421.6929
go-.,;..... (http://alberta.ca/)

Page No.00312
C u rre n t U s e r NHBPS Test_Staff 1
Home Bulkier search Appncaiton Search Reports
Warranty Commencement
Registration information
B u ild e r:
U n it C o m m en cem e n t
Mike 0'6n an (13060000000)
D ate
Unit Commencement
N o te s :
Registration Unit ID ® CM o Address 0 Reported Date 0 Actions
15RU1249653 22-22-42342343 aoca 01 06/20 1G 0
1 -1 of 1 items
Cancel

Government of Alberta Government

10155- 102 Street
Edmonton. A 6 T 5 J 4L4 Canada
H Homewairanty InquJtiesQgov ad.ca
O www hornet arrant) aloerta ca
1 866 421 692S

Page No.00313
Current User NHBPS Test Staff 1
NHBPO Staff Console

'• Reset Filter
Actions Application ID (/MinistryConsoleGrid/GetAilRegistrations?MinistryRegGrid-sort=RegistrationNo-asc)
ft(/O c c u p a n c y ? ld = b c 2 1 1 6 2 7 -8 c 9 f-e 5 1 1 -8 0 a J-0 0 5 0 5 6 a f7 e 8 3 )
& (/P d f/P h n tA p p ? id = t5 R E 1 1 2 7 3 5 9 ) y 15RE1127359 (/BuiiderConsole/LoadRegistration?appNumber=15RE1127359)
A (/P d f/P rin tC e rt? id = 1 5 R E 1 1 2 7 3 6 9 )
f t (/O cc u p a n cy ? id = 8 3 a e 3 4 3 5 -f3 9 d -e 5 1 1 -B 0 i:b -D 0 5 0 5 6 a f7 e 8 3 ) |
A (/P d f/P rin tA p p ? id = 1 5 R E 1 1 2 7 0 5 1 ) y 15RE1127051 (/BuilderConsole/LoadRegistration?appNumber=15RE1127051)
A (tP d flP rm lC e rt? id = 1 5 R E 1 1 2 7 0 5 1)
f t (/O cc u p a n cy ? id = 4 7 9 0 9 b 4 0 -2 a 9 9 -e 5 1 1 -80 c b -0 0 5 0 5 6 a r7 e 8 3 )
A (/P d b P rin tA p p ? id = 1 5 R E 1 1 2 6 5 1 6 ) y 15RE1126516 (/BuilderConsole/LoadRegistration?appNumber=15RE1126516)
A (tP d flPrin tCe rt?id = 1 5 R E 11 2 6 5 1 6)
f t (/O cc u p a n cy ? id = 7 c8 6 d B 2 1 -2 9 9 9 -e 5 1 1 -8 0 c b -0 0 5 0 5 6 a f7 e 8 3 )
A (/P d f/P rin tA p p ? id = 1 5 R E 1 1 2 6 2 6 7 ) y 15RE1126287 (/BuilderConsote/LoadRegistration?appNumber=15RE1126287)
A (/P d t/P rin tC e rt? id = 1 5 R E 1 12 6 2 8 7 )
f t (/O ccu p a n cy 7 id = fe 6 7 (6 fd -5 9 9 5 -e 5 1 1 -8 0 c b -0 0 5 0 5 6 a f7 e 8 3 )
A (/Fdf/PrintA pp?id= 1 5 R E 1 1 2 6 0 1 3 ) y 15RE1126013 (/Bui1derConsole/LoadRegistration?appNumber=15RE1126013)
A (/P d f/P rin tC e rt? id = 1 5 R E 1 1 2 6 0 1 3 )
f t (/Occu p a n c y ? id -8 9 b 2 9 b 2 7 -4 3 1 D -e 5 1 1 -9 a a 4 -0 0 5 0 5 6 b 7 0 9 7 a )
A (tP d t/ P rin tA p p 7 id = 1 5 R E 1 1 2 0 0 7 0 ) y 15RE1120070 (/BuilderConsole/LpadRegisiration?appNumber=15RE1120070)
A ttP d f/P rin tC e rt? id = 1 5 R E 1 1 2 0 0 7 0 )
f t (/O cc u p a n cy ? id = cb 6 d 8 0 5 7 -7 a 6 8 -e 5 1 1 -a c 3 c-0 0 5 0 5 6 b 7 0 9 7 a )
A l/Pdf/PrintApp?id = 1 5 R E 1 1 2 4 5 12) y 15RE1124512 {/BuilderConsole/LoadRegistration?appNumber=15RE1124512)
A (/Pdf/PrintCfirt?id= 15 R E 1 1 2 4 5 12)
f t (/0 cc u p a n cy ? itf= a 7 fa d a 4 f-6 d 1 3 -e 5 1 1 -8 0 8 7 -0 0 5 0 5 6 b 7 0 9 7 a )
A (PPd (/Prin tA p p ?ld = 15 R E 1 1 2 1 4 2 7 ) y 15RE1121427 {/BuilderConsole/LoadRegistration?appNumber=15RE1121427)
A t/P d fyP rin tC e rt?id = 15 R E 1 1 2 1 4 2 7 )
f t (/ O cc u p a n cy ? id = 2 3 3 a 4 4 b 1 -8 9 6 0 -e S 1 1 -a c 3 e -0 0 5 0 5 6 b 7 0 9 7 a )
A (/P d t/P n n lA p p ? id =1 5 A A 1 1 1 6 7 4 1 ) y 15AA1116741 (/BuitderConsote/LoadRegistration?appNumber=15AA1116741)
A (/Pdf/Prin1CBrt?id=15AA1 1167 4 1 )
ft(/0 c c u p a n c y ? id = d f1 a 8 5 5 b -1 0 5 7 -e 5 1 1 -a c 3 e -0 0 5 0 5 6 b 7 0 9 7 a )
A (/P df/Prrn 1 A p p ?id = l5 A A 1 1 1 6 62 5 ) y 15AA1116625 (/8uilderConsole/LoadRegistration?appNumber=15AA1116625)
A (/Pdf/Prin1Cert7id=15A A11166 2 5 )
3 4 5 6 1 - 10 of 59 items
□

Page No.00314
10155 - 102 Street
B HomeWarranty.inquiries@gov.ab.ca (mailto:HomeWarranty,inquiries@gov.ab,ca)
Q www.hom ewarranty.alberta.ca(http://homewarranty.alberta.ca/)
V. 1.866.421.6929
Government

Page No.00315
(/MinistryConsole)
Occupancy
Builder:
More Noir
Authorization Application Number:
15RE1127359
Project:
Occupancy Information
Registration Unit ID Civic Address Occupancy Date Reported By Reported Date Actions
1-Peanut
Amarbir
15RU1248026 Croissant T6Y 12/25/2015 12/15/2015
Randhawa
7I8
1 1 - 1 of 1 items
® Save Cancel

10155- 102 Street
V. 1.866.421.6929
Page No.00316
J ^ [b ^ v b (k M Government

Page No.00317
Current Us*r: NHBPS Test^Staff 1
Home Bulkier Search Application Search Reports
Occupancy
B u ild e r:
U n it O c c u p a n c y
More Noir
D a te 1 2 / 2 5 / 2 0 15|
N o te s :
Registration Unit ID ( j l Civic Address ® Reported Date ® Actions
l5RU t24SQ 26 1-Peanut Croissant 12*15^2015 ®
1 - 1 of 1 le i
Cancel

Government of Alberta Governmen!

10155- 102 Street
Edmonton, A B T 5 J 414 Canada
S Homewarranty inqtiines,@gov ab ca
0 v-vav hamewarranty alberta ca
1 866.421 6529

Page No.00318
Current U ser N HBPSTest,W P2 (Millennium Insurance Corporation)
Home Batch Upload BuiWer Search Application Search
Warranty Provider Console

All Applications Builder Validation Warranty Confirmation Awaiting Payment Rejected Approved Commencement
Actions Eutlder Name 0 Request ID 0 W P Builder ID 0 Status 0 Date Submitted
D New Rom e Builders 1 5 B V J1 16040 Validation Pending Ju n e 24. 2015
a Noir Owner (1 4 0 B 1 112017) 15BVJ115241 Validation Pending May 26 2015
H 4 D h

Government of Alberta Governm ent
16th Floor Com m erce Place

10155 - 102 Street
Edmonton A 5 T 5 J J L 4 Canada
B HomeWarrantv mquine$-;<t3gov ah ca
© Aviv? nomewarranty .risena ca
^ 1865-421 6929

Page No.00319
Builder Validation
B u ild er Name: Nev< Rom e Builders
New Home Buye

Pnmary C ontact: Julius Caesar
Current U s e r N'HBPS te st_ W F2 (MiBsrr.i
H e n .' Upload Bu -rts Phone Number; (760) 555-5555

©
NHBPO B u ild er ID: 15RB1112258
WP B u ild er ID:
Warranty Provic
Validation Status; Validation Pending
ah Appirca' icns Builder vawatk»i cement
Date Subm itted: 6 24-2015
Actions Builder Name ® Dale Submitted
N«^ Rome Builders Date Com pleted: : June 24 ,2 01 5
Validation ID: 1 :3 V 1 116040 May 20. 2015.
0 Ctose
Government

Page No.00320
New Home Buyer Protection System (A/VarrantyProviderConsole)
Current User: NHBPS Test_WP2 (Millennium Insurance Corporation)

All A p p lic a tio n s B u ild e r V alid atio n W a rra n ty C o n firm a tio n A w aiting P a y m e n t R e je c te d A p p ro v e d Com m encem ent
^ P a y S e le c te d O R e s e t Filter
Actions A p plicatio n ID (A /V P G rid / G e tA llW P R e g is tra tio n s ? W P A IIR e g G rid -s o rt= R e g is tra tio n N o -a s c ) B u ild e r (AW PGrii
v' (/WarrantyConfirmaton/Confirm?id=15BD1177762) ✓ 1 5 R F 1 1 4 6 7 3 6 (/ B u i!d e r C o n s o le / lo a d R e g is tra tio n ? a p p N u m b e r = 1 5 R F 1 1 4 6 7 3 6 ) M ore N oir
✓ (/WarrantyConfirmation/Confirm?id=15BD1192532) # 1 5 R F 1 1 5 6 6 2 2 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 5 6 6 2 2 ) M ore N oir
✓ (/WarrantyConfirmation/Confirm?id=15BD1192271) # 15 R F 1 1 5 6 3 3 7 (/ B u i!d e r C o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r = 1 5 R F 1 1 5 6 3 3 7 ) M ore N oir
✓ (/WarrantyConfirmation/Confirm?id=15BD1191496) ✓ 1 5 R F 1 1 5 5 8 4 8 (/ B u i!d e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5RF11 5 5 8 4 8 ) M ore N oir
✓ (/WarrantyCanfinnation/Confirm?id=15BD1191236) y 1 5 R F 1 1 5 5 6 1 4 {/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 5 5 6 1 4 ) M ore N oir
(/WarrantyConfirmation/Confirm?id=15BD1189745) f 1 5 R F 1 1 5 5 0 5 9 {/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 5 5 0 5 9 ) M ore N oir
v' (/WarrantyConfirmation/Confirm?id=15BD1189245) f 1 5 R F 1 1 5 4 5 6 3 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n 7 a p p N u m b e r= 1 5 R F 1 1 5 4 5 6 3 ) M ore Noir
v* (/WarrantyConfirmation/Confirm?id=15BD1189063) f 1 5 R F 115 4 3 5 3 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 5 4 3 5 3 ) M ore N oir
V (/WarTantyConfirmation/Confirm?id=15BD1188869) ✓ 1 5 R F 1 1 5 4 1 5 7 (/ B u ild e rC o n s o le / L o a d R e g is tra lio n ? a p p N u m b e r= 1 5 R F 1 1 5 4 1 5 7 ) M ore N oir
✓ (/WarrantyCanfirmaMon/Confirm?id=15BD1183275) f 15 R F 1 1 5 1 4 1 6 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 5 1 4 1 6) M ore N oir
1 - 10 o f 2 9 item s
11 2 3

16th F lo o r, C o m m e r c e P la c e
1 0 1 5 5 - 1 0 2 S tre e t
E d m o n to n , A B T 5 J 4 L 4 C a n a d a
S H o m e W a rra n ty .in q u irie s@ g o v .a b .ca ( m a ilto :H o m e W a rra n ty .in q u irie s @ g o v .a b .c a )
0 w w w .h o m e w a rr a n ty .a lb e rla .c a (h ttp://hom ew arranty.alberta.ca/)
^ 1 .8 6 6 .4 2 1 .6 9 2 9
............ . (http://alberta.ca/)

Page No.00321
(/WarrantyPro viderConsole)
C u rre n t U ser: NHBPS Test„WP2 (Millennium Insurance Corporation)
Warranty Confirmation
R egistra tio n ID: 15RF1146736
B uild er Name: More Noir
W P B u ild e r ID: 234234234
Project:
L o c a tio n : 12-2-123456
Awaiting Warranty Confirmation
Has ad ditio nal 2 -year w a rra n ty on B uildin g En ve lo p e ?
Unit Number Unit ID Location Unit Policy Number
15RU1246590 11-111-1234
15RU1246612 11-111-3232
1 - 2 of 2 items
n Save Changes •G* Reject 0 Cancel (/WarrantyProviderConsole)

Page No.00322
10155 - 102 Street
9 www.homewarranty.aIberta.ca(http://homewarranty.alberta.ca/)
V. 1.866.421.6929
G o v e rn m e n t

Page No.00323
New Home Buyer Protection System (A/VarrantyProviderConsoie)
Current User: NHBPS Test_WP2 (Millennium Insurance Corporation)

All A p p lica tio n s B u ild e r V alid atio n W a rra n ty C o n firm a tio n A w aiting P a y m e n t R e je c te d A p p ro v e d Com m encem ent
P a y S e le c te d C J R e s e t Filter
A ctio n s A p plicatio n ID (A rV P G rid / G e tA IIW P R e g is tra tio n s ? W P A IIR e g G rid -s o rt= R e g is tra tio n N o -a s c)
ft(WarrantyCommenceni0nt?id=a67a12c3-3599-e511-80cb-005056af7e83) S 1 5 R F 1 1 6 3 4 5 2 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 S R F 1 1 6 3 4 5 2 )
f t {/WarrantyCommencement?id=66c3b7c1 -0Q6d-e51 1-ac3e-0Q5056b7D97a) S 15 R F 1 1 5 3 6 8 9 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 5 3 6 8 9 )
f t (/WarrantyCommencement?id=t6586dtf-c863-e51 1-ac3e-005056b7097a) S 1 5 R F 1 1 5 3 1 5 3 { / B u iId e rC o n s o le / L o a d R e g is t ra tio n ? a p p N u m b e r= 1 5 R F 1 1 5 3 1 5 3 )
f t llWarrantyComr™ncement?id=l3ccd346-505e-e511-ac3s-0050S6b7097a) ✓ 1 5 R F 1 1 5 1 9 5 5 (/ B u ild e rC o n s o le / L o a d R e g is tra tia n ? a p p N u m b e r= 1 5 R F 1 1 5 1 9 5 5 )
f t (/WarTantyCommancement?id=071a3baa-c94d-e511-ac3a-t)050S6b7097a) S 1 5 R F 1 1 4 9 4 1 2 (/ B u ild e rC o n s o le / L o a d R e g is 1 r a tia n ? a p p N u m b e r= 1 5 R F 1 1 4 9 4 1 2 )
ft(/WarrantyCommencement?id=d72t142a-734b-e511-ac3e-005056b7097a) S 1 5 R F 11 4 9 0 4 6 (/ B u ild e rC o n s o le / L o a d R e g is tra tia n ? a p p N u m b e r= 1 5 R F 1 1 4 9 0 4 6 )
f t (/WarrantyCommBncement?id=b3dQS0a4-454b'e511-ac3e-005056b7097a) S 1 5 R F 1 1 4 8 8 B 8 (/ B u ild e rC o n s o le fL o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 4 8 8 8 8 )
f t (AiVarrantyComnnencement?id=24457lb1-5805-e511-9aa4-005056b7097a) S 1 5 R F 1 1 2 9 0 6 2 (/ B u ild e rC o n s o le / L o a d R e g is tra 1 io n ? a p p N u m b e r= 1 5 R F 1 1 2 9 0 6 2 )
ft(/WarrantyCommeneement?id=cdc437f4-elD3-e5l1-9aa4-00S056b7097a) S 1 5 R F 1 1 2 8 7 2 9 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 2 8 7 2 9 )
f t (A/VarrantyCommencement?id=6ee4edf1 -eat]3-e511-9aa4-t305 056b7097a) S 1 5 R F 1 1 2 8 4 2 5 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 R F 1 1 2 8 4 2 5 )
1 - 10 of 11 item s

16th F lo o r, C o m m e r c e P la c e
1 0 1 5 5 - 1 0 2 Stre e t
Ed m o n to n , A B T 5 J 4 L 4 C a n a d a
S H o m e W a rra n ty .in q u irie s@ g o v .a b .ca (m aitto:H o m e W a rr a n ty .in q u irie s@ g o v .a b .c a )
Q w w w .h o m e w a rra n ty .a lb e rta .c a (h ttp ://h o m ew arranty.alb erta.ca/)
^ 1 .8 6 6 .4 2 1 .6 9 2 9
G o ve rn m e n t

Page No.00324
(AA/arrantyPro viderConsole)
Current User: N H B P S T e s t _ W P 2 (M ille n n iu m In s u r a n c e C o r p o r a t io n )
Builder:
M o re N o ir
1 5 R F 1 163452
Project:
W TF
Unit Commencement
R e g is t r a t io n U n it ID C iv ic A d d r e s s P o lic y N u m b e r C o m m e n c e m e n t D a te R e p o rte d B y R e p o rte d D a te A c t io n s
15RU 1246969 2 2 -3 3 3 -4 5 6 7 w tf-4 5 6 7 n h b p s .t e s t s t a f f 1 © g o v .a b . c a 12/14/2015
15RU 1247049 2 2 -3 3 -4 5 6 8 w tf-4 5 6 8 n h b p s . t e s t s la f f l © g o v .a b . c a 12/14/2015
B Save Can cel

1 6 th F lo o r , C o m m e r c e P la c e
1 0 1 5 5 - 1 0 2 S tre e t
H H o m e W a r r a n t y .in q u ir ie s @ g o v .a b .c a (m a ilt o :H o m e W a r r a n t y .in q u ir ie s @ g o v .a b .c a )
© w w w .h o m e w a r r a n t y .a lb e r t a .c a (h ttp :/ / h o m e w a rr a n t y .a lb e rta .c a / )
C 1 .8 6 6 . 4 2 1 .6 9 2 9
Govern,, 0, (http://alberta.ca/)

Page No.00325
Current U ser NHBPS Test_WP2 (Millennium Insurance Corporation)
Home Eatcti upload BwHer Searcti App&caticn Searcti
R e g is t r a t io n In f o r m a t io n
Builder:
U n it C o m m en cem ent
More Noir
Unit Commencement
Registration Unit ID ® Civic Address ® Reported Date ® Actions
15RU1246969 22-333-4567 b ca 12-14 2015 0
15RU1247049 22-33-4568 b ca 12/14/2015 0
1 - 2 of 2 items
- m ■ - Cancel

Governm ent
16m Floor, Commerce Place
10155- 102 Street
Edmonton. A5 T5J 41-1 Canada
25 HomeWarranty inquirt" vojgov at) ca
O Av.vtr homewarranty alberta ca
V. 1 86S 421 5929

Page No.00326
New Home Buyer Protection System (A/VarrantyProviderConsole)
Current U ser NHBPS Test_WP2 (Millennium Insurance Corporation)
Builder Search
•f R e sid e n tia l B u ild e rs
•f O w n er B u ild e rs
Search By:
B u ild e r N a m e :
B u ild e r N a m e
N H B P O B u ild e r ID :
N H B P O B u ild e r ID
W P B u ild e r ID
Q. Se a rch
A ctio n s B u ild e r N a m e (/ B u ild e rS e a r c h / G r id D a ta R e q u e s t? B u ild e rS e a r c h G rid -s a r t= B u ild e rN a m e -a s c )
E x a m p le C o m p a n y (/ O rg a n iz a tio n P ro f]le / B u ild e r? b u ild e rld = f4 0 8 ccf5 -7 3 1 b -e 5 1 1 -8 0 8 7 -

0 005056b7097a)
□ 1 2 5 8 5 2 0 7 7 7 A lb e rta Ltd (/ O rg a n iz a tio n P ro file / B u ifd e r? b u ild e rld = 2 9 0 0 9 0 7 2 -fd 2 3 -e 5 1 1 -8 0 8 7 -

005056b7097a)
N o ir O w n e r ( 1 5 O B 1 3 3 3 6 8 1 0 ) (/ O rg a n iz a tio n P ro file / B u i[d e r? b u ild e rld = 4 b 0 4 6 6 8 2 -9 8 2 5 -e 5 1 1 -

0 8 0 8 7 -0 0 5 0 5 6 b 7 0 9 7 a )
G e n g is K h a n (1 5 0 B 1 2 5 3 0 9 6 8 ) (/ O rg a n iz a tio n P ro file / B u ild e r? b u ild e rld = 8 2 d 6 8 3 0 7 -0 c f4 -e 4 1 1 -

0 9 a a 4 -0 0 5 0 5 6 b 7 0 9 7 a )
J o e y T o m a to e (/ O rg a m z a tio n P ro file y B u ild e r? b iJild e rld = 1 2 9 9 2 c 6 1 -a 1 f5 -e 4 1 1 -9 a a 4 -

0 005056b7097a)
B u ild e r W K 0 0 0 1 (/ O rg a n iz a tio n P ro file / B u iid e r? b u ild e rld = e 1 f8 a 3 a 4 -b 6 f5 -e 4 1 1 -9 a a 4 -

0 005056b7097a)
C a r l K le in ( 1 5 0 B 1 2 8 3 6 2 5 5 ) (/O rg a n iza tio n P ro f]le / B u ild e r? b u ild e rld = 9 1 b c O O a b -b 7 f5 -e 4 1 1 -9 a a

0 005056b7097a)
W K T e s t B u ild e r (/ O rg a n iz a tio n P ro file / B u ild e r? b u ild e rld = a 1 8 8 9 9 4 d -b 9 f5 -e 4 1 1 -9 a a 4 -

0 005056b7097a)
0 Ei (/BuilderConsole/Create?but(der=e19bbed9-b9f5-«411-9aa4-C05056b7097a)
L e e r o y J e n k in s In c. (/ O rg a n iz a tio n P ro file / B u ild e r? b u ild e rld = e 1 9 b b e d 9 -b 9 f5 -e 4 1 1 -9 a a 4 -
005056b7097a)
M iddle N a m e Ltd . (/ O rg a n iz a tio n P ro file / B u ild e r? b u ild e rld = a f6 c 1 e 1 2 -b ff5 -e 4 1 1 -9 a a 4 -

0 005056b7097a)
| 1 2 3 4 5 6 7 8 9 10 ... 1 - 10 o f 151 item s

16th Flo o r, C o m m e r c e P la c e
1 0 1 5 5 - 1 0 2 S tre e t
Page No.00327
SB H o m 0 W a rra n ty .in q u irie s @ g o v .a b .c a (m a ilto :H o m e W a rra n ty .in q u irie s @ g o v .a b x a )
© w w w .h o m e w a rr a n ty .a lb e rla .c a (h ttp ://h o m ew arranty.alb erta.ca/)
<-1.866.421.6929
0 ., (http://alberta.ca/)

Page No.00328
(AA/arrantyProviderConsole)
Current User: NHBPSTest_W P2 (Millennium Insurance Corporation)

A pplication ID
Status
Draft
A pplication Date
Builder Information
B uilder Name
.... .... ................. ........... .
Leeroy Jenkins Inc.
User Name
Phone
Email
Page No.00329
Building ID
Project Name
Building Name
Construction Type
Building Type
Single-Family Detached ▼
Building Sub-type
Site-Built ▼
M unicipality
□ This building is a condom inium o r part o f a condom inium developm ent.
□ This building w ill have an additional 2 years building envelope coverage.
Warranty
W arranty Provider
/—■...i. ' ■ i S
Millennium Insurance Corporation
Building Location
Building Location
Units
Unit Number Location Line Policy Number Registration Unit ID

Page No.00330
Unit
Location
Save and Submit Save As Draft Cancel

10155- 102 Street
V. 1.866.421.6929
Government

Page No.00331
Builder Name User Name Phone
Leercy Jenkins !nc
Email
Building ID Project Name Building Name
Unit Location
Construction Type
Address Type
New Construction
Civic Address T
Municipality
© Add new address
This building Is a cc Street Number Street Name Street Suffix Street Type Street Direction Postal Code
This building will ha Lot. Block/Plan
Warranty ©Add Lob Slock. Plan
Warranty Provider Lot Stock

Millennium insurance Legal Descnptlon Type
ATS Standard
Building Locatior
Sufldsng Local Wn ©Add ATS Standard
Legal Subdivision Quarter Township Range

Units
IW H B Cancel
Unit Number
Save and Submit Save As Drar Cancel

G o v e rn m e n t of A lbe rta
Government

Page No.00332
Current User: NHBPS Tesl_WP2 (Millennium Insurance Corporation)
Home Batch Upload Builder Search Application Search
W arranty Provider C onsole

All Applications Bulkier validation Warranty Confirmation Awaiting Payment Rejected Approved Commencement
T t Pay Selected
Actions Appficatlon ID ® 3uikJer ® Pro|e-:t ® Municipality ® Builder id ® Location ® Status ® Submitted Date T ®
Jack s Payment Test 99-9&S- Awaitmg
/I5RF11SS030 More Ncir December 15 2015
Payment

Government of Alberta G overnm ent

10155-102 Street
Edmonton. A3 T5J 414 Canada
E HomeWarranty inqutrisslfrgov at> ca
O www ho mewar runty alberta ca
1 886421.6929

Page No.00333
Current User, NHSPS Test_WP2 (Mitenmun insurance Corporation)
Home Batch Upload Butsoer Search Application Search
Registrations Invoice 16IV00653979

15RF1166030
Registration Invoice
Builder Name: NHSPO Builder ID:
More Noir 15RB1314105"
Registration Form ID: Warranty Provider
15RF1166030 MiBenmum insurance Corporation
Date Submined:
2015-12-15
Property Type: Total Number of Units:
Single-Family Detached Sue-Built 1
Warrantable Common Property? Additional Warranty on Building Envelope?
NO No
Unit Information
Registration Unit ID Physical Address Legal Description LINO Amount
15RU1250285 99-995-9999 $55 00
1 units SS5.C0
Invoice Total
Total:
S95 00
$ Pay Now i*Prrni 0 Cancel

Page No.00334
A c c o u n t N H B P O P a y m e n ts U A T is in test m o d e
Name: Millennium Insurance Corporation

Phone Number:
Address Line 1:
Address Line 2:
City:
Province: Alberta
Postal Code:
Country: Canada ▼
Email: nhbpswp2@gmail.com
E3
Payment processing
powered by TD
V IS A
Invoice/Order Number: 16IV00653979
Amount: $95.00 CAD
Name on card:
Credit Card Type: VISA T
Credit Card Number:
Expiration Date: 01 T /
Submit Payment

Page No.00335
(/BuilderConsole)
Current User: noir res
Builder Profile
Legal Name#
More Noir
Company Type#
Partnership ▼
Builder Type#
® Residential Owner
Doing Business As
Doing Business As
P h o n e (999) 9 9 9 -9 9 9 9 #
(780) 234-2234
F a x (999) 999-9999
Fax
Website
Website
Physical Address
Address Line 1 #
34 Noir St.
Address Line 2
Address Line 2 Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00336
C ity *
Edmonton
P ro v in c e *
Alberta T
Postal Code A9A 9 A 9 *
H3H 3H3
Mailing Address
Physical & mailing addresses are: the same o different
Save Cancel

10155 - 102 Street
S NHBPS.access@gov.ab.ca (mailto:NHBPS.access@gov.ab.ca)
V. 1.866.421.6929

Page No.00337
M berb^m Government (http://alberta.ca/)

Page No.00338
(/BuilderConsole)
Builder Profile
First N a m e #
Pius
M id d le N am e
Middle Name
Last N a m e #
Four
E m ail A d d r e s s #
Phone (999) 999-9999#
(780) 243-3213
Cell (999)999-9999
Cell
Fax (999) 999-9999
Fax
Save Cancel

Page No.00339
10155- 102 Street
B NHBPS.access@gov.ab.ca (mailto:NHBPS.access@gov.ab.ca)
& www.homewarranty.alberta.ca(http://homewarranty.alberta.ca/)
V. 1.866.421.6929
G overnm ent

Page No.00340
(/BuilderConsole)
Builder Profile
Add New
First Name Last Name Email Phone Contact Type Options
(780) 234 /
Pius Four noir.plusfour@mailinator.com Person In Control
2342 X
(780)234- Person of
Plus Four noir.plusfour@mailinator.com /
2342 Authority
1 1 - 2 of 2 items

10155 - 102 Street
3 NHBPS.access@gov.ab.ca (mailto:NHBPS.access@gov.ab.ca)
V. 1.866.421.6929
G overnm ent (http://alberta.ca/)

Page No.00341
(/BuilderConsole)
Builder Profile
Details
First Nam e#
t \
First Name
Middle Name
.1 ... I II. ■ ■ ■ ■ ■ ■ ...................................... V
Middle Name
Last Nam e#
/ " ......... . . I ........................ *
Last Name
Email Address#
t ■*
Email Address
P h o n e (999) 999-9999#
r " ^
Phone
Cell (999) 999-9999
Cell
F a x (999) 999-9999
t ^
Fax
Contact Types
□ Person In Control □ Person of Authority

Page No.00342
Add Cancel

10155 - 102 Street
V- 1.866.421.6929

Page No.00343
(ABuilderConsole)
Organization User List

Builder Account:
ABC Corp.
New Builder Add Existing User Request New User
First Name Last Name Position Role Email Phone Options
123-123
noir res test Administrator changerb@gmail.com
8907
1 -1 of 1 items
□

10155-102 Street
V. 1.866.421.6929
Government

Page No.00344
(/BuilderConsole)
R eq ue st A p p lica tio n R ole C hange

User Information
F ir s t N a m e
noir
L a s t N am e
res
Phone
123-123-8907
E m a il A d d r e s s
t------------------------------------------------
changerb@gmail.com
P o s it io n /T it le
test
O r g a n iz a t io n 4ft
ABC Corp. ▼
U ser R o le #
User • Administrator
Submit for Approval Cancel

Page No.00345
10155 - 102 Street
H NHBPS.access@gov.ab.ca (mailto:NHBPS.access@gov.ab.ca)
V. 1.866.421.6929
Government

Page No.00346
(/BuilderConsole)
New Company Registration

Company Details
Legal N a m e #
Legal Name
Com pany T y p e #
- Select - T
B u ild e r T y p e #
« Residential Owner
D o in g B u s in e s s A s
Doing Business As
Phone#
Phone
F ax
Fax
W e b s ite
Website
Physical Address
A d d re s s L in e 1 #
Address Line 1
Page No.00347
Address Line 2
Address Line 2
C ity #
City
Province#
Alberta ▼
Postal C od e#
Postal Code
Mailing Address
Physical & mailing addresses are: O the same o different
Address Line 1 #
Address Line 1
Address Line 2
Address Line 2
C ity #
City
Province#
Alberta T
Postal C od e#
Postal Code
Primary Contact
First Nam e#
First Name
Middle Name
Page No.00348
Middle Name
Last Nam e#
Last Name
Email Address#
Email Address
Phone#
Phone
Cell
Cell
Fax
e
Fax
Person in Control
The Person in Control is: O the Primary Contact O Someone Else
First Nam e#
t
First Name
Middle Name
t
Middle Name
Last Nam e#
Last Name
Email Address#
t
Email Address
Phone#
/ 11 ...... . 1
Phone
Cell
Cell
Page No.00349
Fax
Fax
Person of Authority
The Person of Authority is: the Prim ary C ontact the Perso n in Controt o Som eone E ls e
First Name#
First Name
Middle Name
Middle Name
Last Nam e#
Last Name
Email Address#
Email Address
Phone#
Phone
Cell
Cel!
Fax
Fax
NHBPS User
The currently logged in user will be made the administrator of this new builder.

Page No.00350
G ove rn m e n t o f A lberta
10155 - 102 Street
V. 1.866.421.6929
Government

Page No.00351
(/BuilderConsole)
A dd E xisting U ser to O rganization

Select Existing User & Assign Role
O rg a n iza tio n #
ABC Corp. ▼
U s e r#
Freida Fairweather (ffcoldoutside@t ▼
U se r R o le #
User • Administrator

G o ve rn m e n t o f A lberta
10155 - 102 Street
B NFIBPS.access@gov.ab.ca (mailto:NFIBPS.access@gov.ab.ca)
V. 1.866.421.6929

Page No.00352
y^dh&rbc^m Government

Page No.00353
(/BuilderConsole)
NHBPS Access Request on behalf of a User

New User Information
F irs t N a m e #
First Name
Last N am e#
Last Name
Phone#
Phone
Em ail A d d re s s #
Emaii Address
P o sitio n / Title #
Position/Title
ABC Corp. ▼
U se r R o le #
User Administrator

Page No.00354
10155- 102 Street
1.866.421.6929
Government

Page No.00355
New Home Buyer Protection System (/BuilderConsole)
C u r r e n t U s e r: noir re s
Residential Builder Console

All A p p lic a tio n s D ra fts A w aiting P a y m e n t R e je c te d A p p ro v e d Com m encem ent O ccup an cy
+ C r e a t e A p plicatio n + C r e a te R e n ta l Exe m p tio n R e q u e s t V alidation
P a y S e le c te d Q, Enter application ID Se a rch £3 R e s e t Filter
A ctio n s Application ID (/BuilderConsoteGrld/GetAIIBuilderRegistrations?BuilderA!SRegGrid-sort=Registra
y 15RF1166446 (/BuilderConsole/LoadRegistration7appNumber=15RF1166446)
□ $ (/P aym e n t/P a y ln v o lce 7 id = b 6 3 4 a b 7 7 -4 7 a 3 -e 5 1 1 -8 0 cf-0 0 5 0 S 6 a fT o 8 3 ) y 15RF1166030 (/BuilderConsole/LoadRegistration?appNumber=15RF1166030)
U $ (/P aym e n t/P ay!n ra lcB ? ld = 1 a 14 a 8 20 -1 b a 0 -e 5 11 -8 0 c d -0 0 5 0 5 6 a f7 9 8 3 ) y 15RF1164686 (/BuilderConsole/LoadRegistration?appNumber=15RF1164686)
$ (/P a y m e n t/P ay 1 n vo ica 7 id = e a fa d 3 0 4 -1 b a 0 -e 5 1 1 -8 0 cd '0 0 5 0 5 6 af7 e 8 3 ) y 15RF1164444 (/BuilderConsole/LoadRegistration?appNumber=15RF1164444)
$ (/P a y m e n t/P a y lfiv o ic a ? id = 3 6 fe e 2 sb -1 a a 0 -e 5 1 1-80 cd -0 0 50 5 6 af7 e8 3 | y 15RF1164276 (/BuilderConsole/LoadRegistration?appNumber=15R F1164276)
$ {/P aym e n t/P a yln va ic0 ? id = 3 O 3 4 c6 d 3 -1 a a O -e 5 1 1 -8 0 cd * 0 0 5 0 5 6 a f7 e B 3 ) y 15RF1164085 (/BuilderConsole/LoadRegistration?appNumber=15RF1164085)
^ (/ O cc u p a n cy ? id = b c2 1 1 6 2 7 '8 c9 f* e 5 1 1 -8 0 cd -0 0 5 0 5 6 a f7 e B 3 }
£ (/Pdf/PrintApp?id=1 S R E 1 1 2 7 3 5 9 ) y 15RE1127359 (/BuilderConsole/LoadRegistration?appNumber=15RE1127359}
£ |/Pdf/PiintCert7id=15 R E 1 1 2 7 3 5 9 )
# (/O cc u p a n cy ? id = 8 3 a e 3 4 3 5 -f3 9 d -e 5 1 1 -80 cb -0 0 5 0 5 6 a f7 e 8 3 )
£ (/P d flP rin tA p p ? ld = 1 5 R E 11 2 7 0 5 1 ) y 15RE1127051 (/BuilderConsole/LoadRegistration?appNumber=15RE1127051)
£ (/Pdf/Pri n tC e r1 7 id = 1 5 R E 1 1 2 7 0 5 1 )
2 3 4 5 6 7 8 9 10 ... 1 - 10 o f 119 items

16!h Flo o r, C o m m e rc e P la c e
1 0 1 5 5 - 1 0 2 S tre e t
S H o m e W a rra n ty .in q u irie s@ g o v .a b .ca (m a ilto :H o m e W a rra n ty .in q u irie s @ g o v .a b .c a )
0 w w w .h o m e w a rra n ty .a lb e rta .c a (h ttp ://h o m ew arranty.alb erta.ca/)
L 1 .8 6 6 .4 2 1 .6 9 2 9
Government (h«pd/alberta.ca/)

Page No.00356
suisasH ;oc*i • i M ^ o r. 9 i z i 9 ! . r
3 "
paAoidtV 3 Aaqov Z ! V sneu laajjs uojuoujpg pafOJd 1U3DUIA itON ajon lo o iz n w s i / □ . o
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iusujfey 6ui}ic.v.v 911 ~I91 S W N 9C 9f jsisuiiuoAon -&1CX JtONsion SHCWI r J»J$i /
ruaujAed fhiuewy ■res MU3A l uiemuaiM aie» j]ON ajopi 'j« rs u d w s i / □

waiuAed Buiubmv 9UB1 AvoUS P Z ssei sSirnsEH 9101 J10N3X>W m r - jU ib b i / H
luaujAPd BinyBwv tpeag Apues 9 P ijoaupan SIC* iiOMaioi'j M S M itja e i /
D |
tuaujAey Bib-jemv SI/Sl'SL
5666-565-65 asqv iiON sion OSl^SlUbSl ✓
jsai juaiuABd s,5per D
uoilBiU-njuoo
16QA51 MS snuaAV Z 9 60t AjeBieo flON SJOpi aC99lHdSl ✓
%eiieM Buiiiew
P580JU3-aQ igOAJl'MN
uofletiuuuoo
AiUFUBMBl«ewV 031 |V.N* irusiiiasi S
snieis ® a japiAOJd XiucucVi ® 01USTieTtrirV S'JOIPV r
uoiiep'IQA iaenbat) ..- .-tus t> PS08BSted £
uoQcwir/. isanbay /* uopdunxBrtrjijayatedJO+ I uoqeDnddvsjeauD+
ADUBdrJX) jjauia-.M ..:- ir o & v.:..dity c-.--5?ay iu a «ite y fu r,* '.'? «:.•»' 2 OJOqB3i|<JdVBV
9|osuoq J0 p||ng iB jtuapjsay
j 3*4 ?jo >‘i K«P|m e sc Bu ih jo m ur.iiBj-siui^pv :uno33v ajyoJd japing ip je a s tioqedqdtty sluch
sai iicu :iasn luauno

lu 9 } sA $ u o f p d i o j f j jd A n g 3 l u o h /i/isyy

Page No.00357
(/BuilderConsole)

Application ID
Status
Draft
Application Date
Builder Information
Builder Name
t
More Noir ▼
User Name
f"" —— .
Phone
r
Email
Page No.00358
Building ID
Project Name
Building Name
Construction Type
Building Type
Single-Family Detached T
Building Sub-type
Site-Built ▼
Municipality
Warranty
Warranty Provider
.............. .. ............... »
The Alberta New Home Warranty ▼
Request Validation
Building Location
Building Location
n itn Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00359
A JM IL O
Unit
Location

10155 - 102 Street
V. 1.866.421.6929
G o v e rn m e n t

Page No.00360
Email
Building information
Construction Type Building Type Building Sub-type
New Construction Slngte-FamiN Detached Slte-Eu-J'.
Municipality
Unit Location
Address Type
This building is a cc Civic Address
. This building will ha

® Add new address
Warranty
Street NumDer Street Name Street Type street Direction Postal Code
Warranty Provider
LotBlock/Pian
TheAlbertsNe.v h
® A c c L0L5k>cnPlan
Building
Lot
Binding Locaton Legal Descnption Type

A T S Standard
Units
® Add A T S Standard
Legal Subdivision Quarter Township Range
I Cancel
Save and Subm*

Governmeni of Alberta Government
15th Floor Commerce Piaee

10155 - 102 Stress
Edmonton. A S T5 j u l - Canada

Page No.00361
(/BuilderConsole)

P a rti
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Primary Applicant

Name on Title*
Momo nn Title Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00362
XGII I I C U l l I IUC
Authorized Person*
/■ ...................... ■ 1
Authorized Person
Email Address*
............ . 1 1
nam e@ sam ple.com
Phone*
/ .........................
Phone
Physical Address
Address Line 1*
Address Line 1
Address Line 2
Address Line 2
City*
City
Province
Select Province... T
Postal Code*
Postal Code
Mailing Address
Agreement*
I am requesting a rental exemption under Section 3 of the N ew Hom e B uyer Protection Act. I agree
to the following term s and conditions by clicking the submit button.

Page No.00363
1understand that Pursuant to Section 3.1 (8) of the Act, when this designation is registered on the
The Subm it button above sends the online version o f your application to the NHBPO, you w ill then view yo ur
fee sum m ary page w here you can confirm your fees and dow nload the form so you m ay com plete your
application.
To com plete your application, a printed copy o f the application signed by each a pp lica n t m ust be sent to the
New Hom e Buyer Protection Office, 16th Floor, Com m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J
4L4.
P a ym e nt Inform ation
You may pay online or o fflin e , please S ubm it and proceed to the Fee Sum m ary page.
P rivacy S ta te m e n t
The collection of personal inform ation is necessary to support the N ew Home Buyer Protection Program . The
collection is authorized under section 33(c) o f the Alberta Freedom o f Information and Protection of
Privacy(FOIP) Act and w ill be m anaged in accordance with the privacy provisions in the Act. If you have
questions regarding the collection o f your personal inform ation, please send your inquiry to the New Home
Buyer Protection Office, 16th Floor,Com m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

Page No.00364
10155 - 102 Street
1.866.421.6929
G o v e rn m e n t

Page No.00365
(/BuilderConsole)

Required fields are m arked w ith
P a rt 1
Appiicant(s)
P art 2
Builder Information
P art 3
New Building
P art 4
Verification
A co-applicant is anyone w ho shares the title o f the proposed property. You

m ust identify all co-applicants.
Name on Title*
N h m n r\r\ Alberta Municipal Affairs Information Request 2015-R-0088
Page No.00366
iMai l i e u i i i m e
Authorized Person*
t ...
Authorized Person
Email Address*
nam e@sam ple.com
Phone*
Phone
Physical Address
Address Line 1*
Address Line 1
Address Line 2
Address Line 2
City*
City
Province
Postal Code*
Postal Code
Mailing Address
Agreement*
I am requesting a rental exemption under Section 3 of the N ew Hom e B uyer Protection Act. I agree
to the following term s and conditions by clicking the submit button.

Page No.00367
: 1understand that Pursuant to Section 3.1(8) of the Act, when this designation is registered on the
H Save as Draft H Cancel Changes Next y
S u bm ission Instructions
The Subm it button above sends the online version o f yo u r application to the NHBPO, you w ill then view your
fee sum m ary page w here you can confirm yo ur fees and dow nload the form so you m ay com plete your
application.
To com plete your application, a printed copy o f the application signed by each a pp lica nt m ust be sent to the
New Hom e Buyer Protection Office, 16th Floor, C om m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J
4L4.
You m ay pay online or o fflin e , please S ubm it and proceed to the Fee Sum m ary page.
P rivacy S tatem e nt
The collection of personal inform ation is necessary to support the New Home Buyer Protection Program . The
collection is authorized under section 33(c) o f the Alberta Freedom o f Information and Protection of
Buyer Protection Office, 16th Floor,Com m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J 4L4 o r
telephone to 1-866-421-6929.

Page No.00368
10155 - 102 Street
BS NHBPS.access@gov.ab.ca (mailto:NHBPS.access@gov.ab.ca)
1.866.421.6929
Government

Page No.00369
(/BuilderConsole)

Required fields are marked with £ .
Part 1
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
More Noir
Contact Person Legal Name*

f aa...... ........
Plus Four
Phone Number*
r ■■
(780) 243-3213
Email Address

Page No.00370
K Previous H Save as Draft M Cancel Changes Next >
The Subm it button above sends the online version o f your application to the NHBPO, you w ill then view your
fee sum m ary page w here you can confirm yo ur fees and dow nload the form so you m ay complete your
application.
To com plete your application, a printed copy o f the application signed by each a pp lica nt must be sent to the
New Hom e Buyer Protection Office, 16th Floor, Com m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J
4L4.
P aym ent Inform ation

You m ay pay online or off line, please Subm it and proceed to the Fee Sum m ary page.
The collection o f personal inform ation is necessary to support the New Home Buyer Protection Program. The
collection is authorized under section 33(c) o f the Alberta Freedom o f Information and Protection o f
questions regarding the collection of your personal inform ation, please send your inquiry to the New Home
Buyer Protection Office,16th Floor,Com m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

10155- 102 Street
V. 1.866.421.6929
Government

Page No.00371
(/BuilderConsole)

Part 1
Applicant(s)
Part 2
Builder Information
Part 3
N ew Building
Part 4
Verification
Building ID
f" ' " 1
Unique Building ID (G enerated)
Project Name
Project Name
Building Name
Building Name
Construction Type
t "l
N ew Construction ▼

Page No.00372
B u ild in g T yp e
Multi-Family ▼
B u ild in g Su b -typ e
Rental ▼
M unicipality
Select Municipality... ▼
Num ber o f B u ild in g s
Total Num ber o f U nits (all b u ild in g s)
D etails
Building Address
LIN C (separate m ultiple LIN C 's with a com m a)
L IN C
What type of address best describes the building location?: © | Civic | Q | Rural |
Add Address (/RentalExemption/Create?builder=df49b8b4-02f8-e411-9aa4-

005056b7097a&addrGrid-mode=insert)
Lot/Block/Plan
Add Lot/Block/Plan (/RentalExemption/Create?builder=df49b8b4-02f8-e411-9aa4-


Page No.00373
Lot Block Plan
Legal Location Type

What type of address best describes the building location?: • ats (Alberta Tow nship sy ste m ) stand ard
A T S (Alberta Tow nship System ) Non-standard
Add ATS Standard (/RentalExemption/Create?builder=df49b8b4-02f8-e411-9aa4-

005056b7097a&atsGrid-mode=insert)
< Previous H Save as Draft Cancel Changes Next >
The S ubm it button above sends the online version of your application to the NHBPO, you w ill then view yo ur
fee sum m ary page w here you can confirm your fees and dow nload the form so you may com plete your
application.
To com plete your application, a printed copy o f the application signed by each a pplicant m ust be s e n tto the
New Home Buyer Protection Office, 16th Floor, C om m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J
4L4.
P a ym e n t Inform ation
You m ay pay online or o fflin e , please Subm it and proceed to the Fee Sum m ary page.
collection is authorized under section 33{c) o f the Alberta Freedom o f Inform ation and Protection o f
questions regarding the collection o f your personal inform ation, please send yo ur inquiry to the New Home
Buyer Protection Office,16th Floor,C om m erce Place, 1 0 1 5 5 - 1 02nd Street, Edm onton, AB, T5J 4L4 or
telephone to 1-866-421-6929.


Page No.00374
10155- 102 Street
1.866.421.6929
Government (http://alberta.ca/)

Page No.00375
(/BuilderConsole)

Part 1
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Applicant(s)
Name On Authorized
Title Person Email Phone Agreement Answered
Bob Smith Bob Smith bobby@gmail.com (780) 638 ✓

1280
Builder
Legal Business Name
More Noir

Page No.00376
C o n ta c t P e rs o n L e g a l N am e
Plus Four
Phone N um ber
(780)243-3213
E m a il A d d r e s s
New Building (Building ID:15BD1214195)

P r o je c t:
R e n t a l : 2 U n its , 1 B u ild in g s
M u n ic ip a lit y : E d m o n t o n

Lot: 1 Block: 12 Plan 123456
Ready for Submission
K Previous H Save as Draft ED Cancel Changes
The Subm it button above sends the online version o fy o u r application to the NHBPO, you w ill then view your
application.
To com plete yo ur application, a printed copy o f the application signed by each a pplicant m ust be sent to the
New Home Buyer Protection Office, 16th Floor, C om m erce Place, 10155 - 102nd Street, Edmonton, AB, T5J
4L4.
You may pay online or o fflin e , please Subm it and proceed to the Fee Sum mary page.

Page No.00377
P rivacy S tatem e nt
The collection o f personal inform ation is necessary to support the New Home Buyer Protection Program . The
collection is authorized under section 33(c) o f the Alberta Freedom o f Inform ation and Protection of
questions regarding the collection o f yo ur personal inform ation, please send your inquiry to the New Home
Buyer Protection Office,16th Floor,Com m erce Place, 10155 - 102nd Street, Edmonton, AB, T5J 4L4 o r
telephone to 1-866-421-6929.

10155 - 102 Street
V- 1.866.421.6929

Page No.00378
Residential BuilderConsole
All Applications Drafts Awaiting Payment Rejected Approved Commencement Occupancy
+ Create Application + Create Rental Exemption ✓ Request Validation
^ Pay Selected a Enter application ID Search C Reset Filter
Actions Application ID (/BuilderConsoleGrid/GetAIIBuilderRegistrations?BuilderAIIRegGrid-sort=Registra
$ (/ P a y m e n t/ P a y ln v o ic e 7 id = b 6 3 4 a b 7 7 -4 7 a 3 ^ 5 1 1 ^ 0 c f-0 0 5 0 5 6 a f7 e 8 3 ) ✓ 15R F1166030 (/BuilderConsole/LoadRegistration?appNumber=15RF1166030)
$ (/Paym enl/PaylnvotcB7id=1 e l 4aB 20-1 b a 0 -e 5 1 1 -80 c d -0 0 5 0 5 6 a f7 e B 3 ) f 1SRF1164686 {/BuilderConsole/LoadRegistration?appNumber=15RF1164686)
$ (/P a y m e n t/P a y ln v o ic e ? id = e a fa d 3 0 4 -1 b a 0 -e 5 1 1 -a 0 c d -0 0 5 0 5 6 a f7 e 8 3 ) f 15RF1164444 (/BuilderConsole/LoadRegistration?appNumber=l5RF1164444)
$ (/Fa ym B n t/P ayln vo ica ? id ” 3 6 fe e 2 a b -1 a a O -e 5 1 1 -B 0 c d -0 0 5 0 5 6 a f7 e 8 3 ) f 15RF1164276 (/BuilderConsole/LoadRegistraiion?appNumber=15RF1164276)
$ (/P aym e n t/P a y ln v o ic e ? id = 3 0 3 4 c 6 d 3 -1 a a 0 -e 5 1 1 -6 0 c d -0 0 5 0 5 6 a f7 e 8 3 ) ✓ 15RF1164085 (/BuilderConsole/LoadRegistration?appNumber=15RF1164085)
$ (/P a y m e n t/P a y ln v o ic e ? id = 2 c8 5 a e b 2 -8 a 9 4 -e 5 1 1 -8 0 c b -0 0 S 0 5 6 a f7 e 8 3 ) f 15RF1161738 (/BuilderConsole/LoadRegistration?appNumber=15RF1161736)
$ (/P aym e n t/P a y ln v o ic e ? id = 2 7 4 7 a B 6 3 -8 a 9 4 -e 5 1 1 -8 0 cb -0 0 5 0 5 6 a f7 e B 3 ) f 15RF1161317 (/BuilderConsole/LoadRegistration?appNumber=15RF1161317)
$ (/P ay m e n t/P ay ln v o ice? id = b 3 f5 f2 9 a -b 9 8 1 -e 5 1 1 -8 0 c9 -0 Q 5 0 5 6 a f7 e 8 3 } f 15RF1157874 (/BuilderConsole/LoadRegistration?appNumber=15RF1157874)
1 - 8 of 8 items
□

10155 - 102 Street
S NHBPS.access@gov.ab.ca (mailto:NH8PS.access@gov.ab,ca)
V. 1,866.421.6929
G overnm ent ( ^ t p . / / a l b e r t a . c a / )

Page No.00379
Current User noir les
Home App*cx*oii Search ft-flcer Prcwe Acccunt AdrrufieTfa'jon WcrXing as Builder. More No
O
Registrations invoice 15IV35655039

15R F1164444
Guilder Harm NHBPO Builder JO
More Nor 15RS13141057
Registration Form IQ: Warranry Provider
J5RF11&4444 The AJberia New Home warranty Program
Oats Submitted.
2015*12-11
3uilding Information
Properry Type: Total Number 01 Units:
Single-Fam#* SiV-Fuii: 1
Warrantable Common Property? Additional Warranty on Building Envelope?
NO No
Unit Information
Registration Unit ID Physical Address Legal Descnptlon LINC Amount
15RU1243663 34-Snav.y Lane 12-34-13424312 S95 0O
1 IM S 39500
Invoice Total
Total;
5?500
$ Pay Now 4. =1101 0 Cancel
Tc per, offlme. please subme a printed copy of Efe Fee Summon aicng with a Cheque. Certified Cheque or Money Order for the total amount pavafrie to Government of
Alberta
NO REFUND^ a I o* m the amcunt af $5C0 00 c-r less Ail re" ai't requests must be re-, n ,-ed i . ui 0fV e ■■: r ‘ ng Artbin 3D buseless rt.T, s ' pn» menT AhsJ refund must
not exceed 5500 00
Please remit to the Mowing address

AJberta Municipal Affairs
16*’ Floor Commerce Fiace
10155 -1 0 2 Street
Ecmontor Aioerta T5j 4L4 Canada
Tel 1-356-421-5929
Fa* 760-427-2538

Governm ent of Alberta G overnm ent
1 6 th Floor,commerce state
10:55 - 1 0 2 Street
Edmonton AB T5j 4L4 Canada
■ NHGPS.aocesS'g&ov ab ca
0 -va.v r <u erta ca
L- 1 86$ 421 5924

Page No.00380
A c c o u n t N H B P O P a y m e n ts U A T is in test m o d e
Name: ABC Corp.

Phone Number:
Address Line 1:
Address Line 2:
City:
Province: Alberta ▼
Postal Code:
Country: Canada ▼
Email: changerb@gmaii.com
Paym ent processing

p o w e re d by TD
V IS A E J
Amount: $95.00 CAD
Name on card:
Credit Card Type: VISA ▼
Credit Card Number:
Expiration Date: 01 ▼ / 2015 ▼
Submit Payment

Page No.00381

+ Create Application + Create Rental Exemption V Request Validation
Pay Selected Q. Enter application ID Search C Reset Filter
Actions Application ID (/Bui]derConsoleGrid/GetAllBuilderRegistrations?BuilderAIIRegGrid-sort=Re'
f t (/W arTa n tyC o m m e n ce m en t? id = a6 7 a 1 2 c3 -3 5 9 9 -e5 1 1 -8 0 c b -0 0 5 0 5 6 a f7 e 8 3 )

# 15RF1163452 (/BuilderConsole/LoadRegistrationTappNumber^l 5RF1163452)
* {/P d f/P rin tC e rt7 id = 1 5 R F 1 1 6 3 4 5 2 )
ft{/W a rra n ty C o m m e n ce m e n t? id = 4 d 2 d 7 2 e 3 -8 0 9 4 -e 5 1 1 -8 D cb -0 0 5 0 5 6 a f7 e 8 3 )
f 15RF1160847 (/SuilderConsoie/LoadRegistration?appNumber=15RF1160847)
f t (/P df/Prin tCert7 id =15 R F 1 1 60 8 4 7)
f t p W a rra n ty C o m m e n ca m e n t? id = 1 0 0 6 0 a 9 f-7 4 7 e -e 5 1 1 -8 0 c9 -0 0 5 0 5 6 a f7 e 8 3 )
# 15RF1156870 (/BuilderConsole/LoadRegistration?appNumber=15RF1156670)
f t f/P d f/P rin tC e rt? id = 1 5 R F 1 1 5 6 8 7 0 )
ft(/W a rra n ty C o m rn o n c e m e n t? id = 6 6 c3 b 7 c1 -0 0 6 d -e 5 1 1 -a c3 e -0 0 5 0 5 6 b 7 0 9 7 a )
f 15RF1153689 (/Bui[derConsole/LoadRegisiration?appNumber=15RF1153689)
f t (/PdfiPri ntCer17id=15 R F 1 1 5 3 6 8 9 )
f t (/W arran tyC om m B n cam e n t7id= 1 6 5 86 d 1 F-c8 6 3 -e 5 11 -ac3 e -0 0 5 0 5 6 b 7 0 9 7 a )

15RF1153153 (/BuilderConsole/LoadRegistration?appNumber=15RF1153153)
f t (/W a rra n ty C o m m e n ce m e n t? !d = 1 7 d b c5 d B -a2 6 D -e 5 1 1 -a c3 e -0 0 5 0 5 6 b 7 0 9 7 a)

f 15RF1152746 (/BuilderConsole/LoadRegistration?appNumber=15RF1152746)
f t (/P d f/P rin tC e rt? id = 1 5 R F 1 15 2 7 4 6 )
f t (/W arra n ty C o m m e n c e m e n t? id = 1 3 cc d 3 4 6 -5 0 5 e -e 5 1 1 -a c3 e -0 0 5 0 5 6 b 7 0 9 7 a )
/■ 15RF1151955 (/BuilderConsole/LoadRegistration?appNumber=15RF1151955)
f t (/P d f/P rin tC e rt7 ld = 15 R F1 1 5 1 9 5 5 )
f t (yW arra n ty C o m m 0 n cB m sn 1 7 id = O 7 1 a 3 b a a -c9 4 d -e 5 1 1 -ac3 e-0 0 5 0 5 6 b 7 0 9 7 a )

S ' 15RF1149412 (/BuilderConsole/LoadRegistration?appNumber=15RF1149412)
f t (/P d f/P rin lC e rt? id = 1 5 H F 1 1 4 9 4 1 2 )
f t (iW a rra n ty C o m m e n ce m e n t? id = d 7 2 M 4 2 a -7 3 4 b -e 5 1 1 -a c 3 e -0 0 5 0 5 6 b 7 0 9 7 a )
# 15RF1149046 (/BoilderConsole/LoadRegistration?appNumber=15RF1149046)
f t (/ W a rra n ty C o m m e n ce m o n t? id = b 3 d 0 5 0 a 4 -4 5 4 b -e 5 1 1 -a c3 e -0 0 5 0 5 6 b 7 0 9 7 a )
S 15RF1148888 (/BuilderConso!e/LoadRegistration?appNumber=15RF1148868)
1 2 3 4 1 - 10 of 35 items

10 1 5 5 - 102 Street
S NH8PS.access@gov.ab.ca (maiUo:NHBPS.access@gov.ab.ca)
V. 1.666.421.6929
Page No.00382
J & ib w b t K M Govern « (http://alberta.ca/)

Page No.00383
Current User noir res
Builder:
More Noir
15RF1163452
Project:
WTF
Unit Commencement
Registration Unit ID Civic Address Policy Number Commencement Date Reported By Reported Date Actions
15RU1246969 22-333-4567 wtf-4567 nhbps.teststaff1@gov.ab.ca 12/14/2015
15RU1247049 22-33-4568 wtf-4568 nhbps.teststaff1@gov.ab.ca 12/14/2015
1 - 2 of 2 items
□
El Save Cancel

Governm ent o f Alberta
10155-102 Street
1.866.421.6929
Go™™™* (http://alberta.ca/)

Page No.00384
N ew Hom e B uyer P rotection System
Currant U sa r nolr res
Home Application Search Builder Profile Account Administration Wording as B u ild e r More New
O
Warranty Com m encem ent

B uilder Registration Num ber Project:
More Moir 15RF1163452 VVTF
Unit Commencement
Registration Unit ID © Civic Address © Reported Date <t 1 Actions
15RU124696S 22-333*4567 b ca 12/14/2015 ©
15RU1247049 22-33-4568 b ca 12/14/2015 ©
BSave Cancel

G o v e rn m e n t o f A lb e rta G ovei nroent
16th Floor. Commerce Race

10155 - 102 Street
Edmonton. AB T5J 4L4 Canada
S NHBPS accessggov ab ca
Q tnuw hcmev.arranty afcerta ca
^ 1 865 421 6529

Page No.00385

A ll A p p lic a tio n s D ra fts A w a itin g P a y m e n t R e je c te d A p p ro v e d C om m encem ent O ccupancy
+ C re a te A p p lic a tio n + C re a te R e n ta l E x e m p tio n V R e q u e s t V a lid a tio n
!1 P a y S e le c te d Q, E nter application ID S e a rc h C R e s e t F ilte r
A c tio n s A p p lic a tio n ID (/B u ild e rC o n s o le G rid /G e tA IIB u ild e rR e g is tra lio n s ? B u ild e rA IIR e g G rid -s o rt= R e g is tra tio n N o -
A( / O c c u p a n e y lid = b c 2 1 1 6 2 7 -8 c 9 f-e 5 1 1 -8 0 c d -0 0 5 0 5 6 a f7 e 8 3 )
A (/P d f/P rin tA p p 7 id = 1 5 R E 1 1 2 7 3 5 9 ) if 1 5 R E 1 1 2 7 3 5 9 (/B u ild e r C o n s o le /L o a d R e g is tr a tio n ? a p p N u m b e r= 1 5 R E 1 1 2 7 3 5 9 }
S( / P d f/P rin tC e rt7 id -1 5 R E 1 12 7 3 5 9 )

f t (/O c e u p a n c y ? id = 7 c 8 6 d 6 2 1 -2 9 9 9 -e 5 1 1-8 D c b -0 0 S 0 5 6 a f7 a 8 3 )
A (/P d f/P rin tA p p 7 id = 1 5 R E 1 1 2 6 2 8 7 ) f 1 5 R E 1 1 2 6 2 8 7 (/B u ild e r C o n s o le /L o a d R e g is tr a tio n ? a p p N u m b e r= 1 5 R E 1 12 6 2 8 7 )
A {/P d S P rin tC ert7 id = 1 5 R E 1 12 6 2 8 7 )
ft( / O c c u p a n c y ? id = fe 6 7 f6 fd - 5 9 9 5 - e S 1 1 -8 0 c b -0 0 5 0 5 6 a f7 e 8 3 )
(IP d r/P rin tA p p 7 id = 1 5 R E 1 1 2 6 d 13) f 1 5 R E 1 1 2 6 0 1 3 ( /B u ild e r C o n s o le /L o a d R e g is tra tio n ? a p p N u m b a r= 1 5 R E 1 1 2 6 0 1 3 )
S ( tP d f / P iin t C e r t ? id = 1 5 R E 1 1 2 6 0 1 3 )
f t (/ O c c u p a n c y ? id = c b 6 d 8 Q 5 7 -7 a 6 8 -e 5 1 1 -a c 3 e - 0 0 5 0 5 6 b 7 0 9 7 a )
A(/ P d f/P rin tA p p ? id = 1 5 R E 1 1 2 4 5 1 2 ) / 15RE1124512 (/BuilderConsote/LoadRegistration?appNumber=15RE1124512)
A (/P d f/P rin tC e rt7 id = 1 5 R E 1 1 2 4 5 1 2 )
f t (/O ccup an cy7ld = 1 e 3 c 1 2 4 0 -b 9 1 9 -e 5 1 1 -8087-O D 5Q 5 6b7 O 97 a)
A (/Pdf/PrintApp?id"= 15 R E 1 1 2 2 3 2 2 ) f 15 R E 1 1 2 2 3 2 2 {/B u ild e r C o n s o le /L o a d R e g is tr a tio n ? a p p N u m b e r = 1 5 R E 1 1 2 2 3 2 2 )
& (/P d f/P rin tC e rt? id = 1 5 R E 11 2 2 3 2 2 )
f t( / 0 c c u p a n c y ? id = 8 6 b e 0 4 f1 -5 d 1 0 - e 5 1 1 -9 a a 4 - 0 0 5 0 5 6 b 7 0 9 7 a )
A (rP d f/P rin lA p p ? rd = 1 5 R E 1 1 2 10 8 7 ) / 1 5 R E 1 1 2 1 0 8 7 (/B u ild e r C o n s o le /L o a d R e g is tr a tio n ? a p p N u m b e r= 1 5 R E 1 1 2 1 0 8 7 )
A(/P d f/P rin lC e rt? id “ 1 5 R E 1 1 2 1 0 B 7 )

f t ( I O c c u p a n c y ? id - e 9 9 b 3 5 c 1 -5 e 0 5 - e 5 1 1 -9 a a 4 -0 0 5 0 5 6 b 7 0 9 7 a )
1=1 (/Pd f/P rin lA p p ? id ~ 1 5 R E 1 1 1 9 3 5 9 ) ✓ 1 5 R E 1 1 1 9 3 5 9 (/B u ild e r C o n s o le /L o a d R e g is tr a tio n ? a p p N u m b e r= 1 5 R E 1 1 1 9 3 5 9 )
A (/P d r/P < in tC e rt?id = 1 5 R E 1 1 19 3 5 9 )
f t {/O ccu p a n cy ?id = cfd d 0 1 e a -5 e e f-e 4 1 1 - a 8 8 1 -0 0 5 0 5 6 b 7 0 9 7 a )
A(/Pdr/Prin tAp p?id= 15 R E 1 1 1 7 3 4 2 ) f 15 R E 1 1 1 7 3 4 2 (/B u ild e r C o n s o le /L o a d R e g is tr a tio n ? a p p N u m b e r= 1 5 R E 1 1 1 7 3 4 2 )
* { /P d 5 P rin tC e rt? td = 1 5 R E 1 1 1 7 3 4 2 )
f t { /0 c c u p a n c y ? id = d a b a 9 fa e -4 e e f-e 4 1 1 -a 8 8 1 -0 0 5 0 5 6 b 7 0 9 7 a )
A(/P d f/P rin tA p p ?id = 1 6 R E 1 1 1 6 3 1 7 ) if 1 5 R E 1 1 1 6 3 1 7 (/8 u ild e r C o n s o le /L o a d R e g is tr a tio n ? a p p N u m b e r = 1 5 R E 1 1 1 6 3 1 7 )
A (/P d f/P rin tC e rt7 :d = 1 5 R E 1 1 1 6 3 1 7 )
f t (/O c c u p a n c y ? id = 8 c d e d c b b -7 1 e B -6 4 1 1 -a 6 c c -0 0 5 0 5 6 b 7 0 9 7 a )
A(/P d f/P rin 1 A p p ?id = 1 5 R E 11 1 5 5 2 7 ) f 1 5 R E 1 1 1 5 5 2 7 (/B u ild e r C o n s a le /L o a d R e g is tr a tio n ? a p p N u m b e r= 1 5 R E 1 1 1 5 5 2 7 )
A (/P d r/P rin tC e rt? id = 1 5 R E 1 1 1 5 5 2 7 )

Page No.00386
1 - 1 0 o f 13 ite m s

1 6 th F lo o r, C o m m e rc e P la ce
1 0 1 5 5 - 1 0 2 S tre e t
& N H B P S .a c c e s s @ g o v .a b .c a ( m a ilto :N H B P S .a c c e s s @ g o v .a b .c a )
Q w w w .h a m e w a r r a n ty .a lb e r ta .c a ( h ttp ://h o m e w a r r a n ty .a lb e r ta .c a /)
V. 1 .8 6 6 .4 2 1 .6 9 2 9
Government
{http://alberta.ca/)

Page No.00387
(/BuilderConsole)
O ccupancy
Builder:
More Noir
Authorization Application Number:
15RE1127359
Project:
1-Peanut
Amarbir
15RU1248026 Croissant T6Y 12/25/2015 12/15/2015
Randhawa
7I8
1 -1 of 1 items
El Save Cancel

10155- 102 Street
C 1.866.421.6929 Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00388
Government

Page No.00389
C u rre n t U s e r noir re s
Home Application Search SuiMer Profit*? Account Administration Worttlng as Builder Mere nou
' o
Occupancy
R e g is tr a tio n In fo r m a tio n
Builder: U n it O c c u p a n c y
More Moir
D a te
N o te s :
Registration Unit ID © Civic Address © Reported Dale © Actions
15RU12JS026 1-Peanut Croissant 12/15/2015 ©

C E OctuptncyDalel
N ew Home Buyer Protection Office

G overnm ent o f AJberta Gove/ nment
1Sth Floor Commerce Place
10155- 102 Street
Edmonton AB T5J 4L4 Canada
3 NHBPS access ojgov aD ca

Q v.v.v. nome/arranty alberta ca
v, 1 S6S 421 6929

Page No.00390
(/BuilderConsole)
Current User: amber fly
Builder Profile
Builder
... i ....... ii s
Mike O’Brian (13O B0000000)
Builder T y p e #
Residential « Owner
Physical Address
Address Line 1 #
567 Testing Avenue
Address Line 2
Address Line 2
C it y #
Edmonton
P ro v in c e #
Alberta T
Postal Code A 9 A 9 A 9 #
A1A2B 2
Mailing Address
Page No.00391
Physical & mailing addresses are: O the same different
Address Line 1 $
1234 Testing Street
Address Line 2
Address Line 2
City#
Edmonton
Province#
Alberta T
Postal Code A9A 9A9#
A1A2B2
Save Cancel

10155 - 102 Street
V. 1.866.421.6929
Govern men

Page No.00392
(/BuilderConsole)
Current User: am ber fly
Builder Profile
First Name#
Mike
Middle Name
Middle Name
Last Name#
O'Brian
Email Address#
amber.fly@mailinator.com
Phone (999) 999-9999#
(780) 222-2222
Cell (999) 999-9999

f----------------------------------------------------------------------------------------- H
Cell
Fax (999)999-9999
Fax
Save Cancel

Page No.00393
10155 - 102 Street
V. 1.866.421.6929
Government

Page No.00394
(/BuilderConsole)
Organization User List

Builder Account:
Owner Builder ▼
Request New User
First Name Last Name Position Role Email Phone Options
123-123 /
amber fly test Administrator amberfly@gmail.com
8907 X
403-885 /
Betty White Owner User betty.owner9999@gmail.com
5599 X
780-675 y*
bob bryenton architect User bbryenton@gmail.com
7865 X
780-345
\
Chriss Kringles Ownerdf User chris.kringle9999@gmail.com
5678
X
Great 780-111 /
Daniel Ward User test021 delta@gmail.com
Builder 2222 X
Owner 123-908 /
externaltest user2 User ext.user.x1 @gmail.com
Builder 7890 X
\
587-555
fake address owner User fakeaddress654123@gmail.com
4444
X
Owner 780-555 /
Henry Holms User henry.holms99@yahoo.ca
Builder 4321 X
587-222 y'
jim homeowner owner User jimhomeowner@hotmail.com
3333 X
780-555 /
Joy Clause owner User mrs.clause99@hotmail.com
7799 X
1 2 3 4 5 6 7 8 9 10 ... 1 - 10 of 1020 items

-----! Alberta Municipal Affairs Information Request 2015-R-0088
Page No.00395
10155“ 102 Street
V. 1.866.421.6929
Government

Page No.00396
(/BuilderConsole)
Request Application Role Change

User Information
First Name
amber
Last Name
fly
Phone
123-123-8907
Email Address
amberfly@gmail.com
Position/Title
test
Owner Builder ▼
User Role#
User * Administrator

Page No.00397
10155 - 102 Street
^ 1.866.421.6929
Government
(http://aiberta.ca/)

Page No.00398
(/BuilderConsole)
NHBPS Access Request on behalf of a User

New User Information
First Name#
First Name
Last Name#
Last Name
Phone#
Phone
Email Address#
Email Address
Position/Title#
Position/Title
Organization#
t — — “ ■>
Owner Builder ▼
User Role#
User Administrator
Submit for Approval Canoe!

Page No.00399
10155 - 102 Street
V* 1,866.421.6929
Government

Page No.00400
------- ------------
Create Registration
Will ycu be building your new house with 3 warranty?
New Home Buye

Current User, amber t,
No
Home Application Search Help me deode what type cf application i need to make >Brian (13000000000)
Owner Builder Console

AMApplications r.raP.s Awa ling r-.vyr^nf Re;-,: ::ed Approved Commencement Ccci:p;i:«cv
+ Create Application
; o r a ; Cl -C.T-" at Search 2 Kf?r,ol Filter I

. ; Actions Application ID ® Builder © Frovv*! ® Municipality © Location 0 Status 0
MiKe O'Brian
C D . / 15RF1165412
(13080000000)
Kate Lake Louise 22-22-42342343 Approved
MlKe O'3nan
□ □ ✓ (652*5
(13060000000)
Kate R-yley 4-5-3-1 Approved
MiKe O'Brian
□ ✓ 15RFM65081
(13080000000)
Kale Smoky Lake 23-23-23454345 Awaiting Payment
Mike O-Biian
* D ' / 1SRFH 64869
(13OE000SCCG)
Kate Andrew 12-12-156454 Av.artmg Pay me.nt
Mike O’Brian
a • □ / I3RE1126516
(13060000000)
At>ee 321 Bias: Otf Wharf Approved
Mike O'Brian Acp

A y 15AA.1t 1692'j Cnampfon 23 2432 Centre. T5L 3E4 AwarUng Approval
(13060000000) Authorization
Mine O'Brian Awaiting Warrant,

.✓ 15RF11-. 1662 AJcomdsiy 7009 49A Avenue
(1208000X00) Conrirma’Jon
Mike- O'Srian Kevm Payment 10303 Fake Street NVV

C D ✓ t5#F1 158426
(13060000000) Test
Acadia Valley
HOH OHO
Approved
MiXe O'Biran Lubicon Lake Northern Sunrise

A y 15REI124883
(13080000000) Band County
20-1-5121430 Cancelled
Mike OBrian LuOlcon Lake Northern Sunrise

4- y !$R£?1247l1
. 20-1-8121430 Awaiting Approval

Page No.00401
(/BuilderConsole)

Part 1
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
Primary Applicant
Primary Applicant Details Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00402
First Name*
Mike
Middle Name*
Middle Name
Last Name*
O'Brian
amber.fly@mailinator.com
Phone*
— ■■■■ — ....... ■■■■■ ^
(780) 222-2222
Cell
Cell Phone
Fax
Fax
Drivers License
Questionnaire
O Yes
O No
O 10 years or more
Page No.00403
O Yes
O No
O Yes
ONo
information:
O Yes
ONo
O Yes
ONo

assessment and
me/us.
O Yes
ONo
□ A life interest
□ Other

Page No.00404
other individuals
property
builder.
O Yes
ONo

authorization.
O Yes
ONo
A ct:
□ None of Above
O Yes
ONo
this document.
O Yes
ONo
Page No.00405
H Save As Draft H Cancel Changes Next >
application.
Payment Information
Privacy Statement
Buyer Protection Office, 16th Floor,Commerce Place, 10155 - 102nd Street, Edmonton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

10155- 102 Street
V. 1.866.421.6929
A \h w b < K M Govoruron! (http://alberta.ca/)

Page No.00406
(/BuilderConsole)

Part 1
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
A co-applicant is anyone who share the title of the proposed property. You
Co-Applicant1 Details Alberta Municipal Affairs InfOrmafionRequ -R-0088

Page No.00407
First Name*
Legal Given Name
Middle Name*
/1 ■ ... i s
Middle Name
Last Name*
....... 11" »
Last Name

i' ..... .... ' »
Email Address
Phone*
/ * " ....... n
Phone
Cell
Cell Phone
Fax
Fax
Drivers License
Questionnaire
O Yes
O No
O less than10 years
O 10 years or more
Page No.00408
O Yes
O No
O Yes
ONo
information:
O Yes
ONo

O Yes
ONo

assessment and
me/us.
O Yes
O No
□ A life interest
□ Other

Page No.00409
________________________________________ ^

other individuals

property
builder.
O Yes
ONo

authorization.
O Yes
ONo
A ct:
□ None of Above
O Yes
O No
this document.
O Yes
O No
Page No.00410
H Save As Draft HDCancel Changes Next ^
The Submit button above sends the online version ofyour application to the NHBPO, you will then view your
application.
Payment Information
Privacy Statement
questions regarding the collection ofyour persona! information, please send your inquiry to the New Home
Buyer Proteclion Office,16th Floor,Commerce Place, 10155 - 102nd Street, Edmonton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

10155 - 102 Street
S HomeWarranty.inquiries@gov.ab.ca (mai[to:HomeWarranty.inquiries@gov.ab.ca)
V. 1.866.421.6929
Govern [pent
Page No.00411
(/BuilderConsole)

Part 1
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
Physical Address
Address Line 1*
/ ■■■- »
Address Line 1
Address Line 2
/■■ 11 ■■■■■■■■■' ' ■ ' 11 1 *
Address Line 2
City*
City Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00412
Province
Postal Code*
Postal Code
Current home & mailing addresses are: ® the sam e o different
Mailing Address
< Previous H Save As Draft H Cancel Changes Next >
application.
Payment Information
Privacy Statement
questions regarding the collection ofyour personal information, please send your inquiry to the New Home
telephone to 1-866-421-6929.

Page No.00413
10155- 102 Street
1.866.421.6929
Government

Page No.00414
(/BuilderConsole)

Part 1
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
New Home Location
You must provide at least one type of location description. Civic/Rural Address, Lot-Block-Plan, or
ATS
Select address type: (•) Civic Address o Rural Address
Civic Address
Building ID:
Page No.00415
Unit Number
Unit No.
LINC
LINC
Street Number
Street No
Street Name
Street Name
Street Type
Select Street Type... ▼
Street Direction
Select Direction... ▼
Municipality
Select Municipality... T
Postal Code
POSTAL CODE
Lot-Block-Plan
Add Lot/Block/Plan (/AuthorizationExemption/Create?builder=f89fce0b-d8e2-e411-9d1b-
Lot Block Plan

Page No.00416
An Ordinarily Resident Adult is anyone over 18 years of age residing in the
home. You must identify all ordinarily resident adults.
Add Ordinarily Resident Aduit (/AuthorizationExemption/Create?builder=f89fce0b-d8e2-

e411-9d 1b-005056b7097a&ResidentsGrid-mode=insert)
Legal Giv... Middle N... Last Nam... Phone {/A... Email (/A... Date of Bi...
No items to display
K Previous H Save As Draft U Cancel Changes Next >
The Subm it button above sends the online version o f your application to the NHBPO, you will then view your
application.
Payment Information
You m ay pay o nline or off line, please Subm it and proceed to the Fee Sum m ary page.
Privacy Statem ent

Buyer Protection Office,16th Floor,C om m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

Page No.00417
10155 - 102 Street
BS HomeWarranty.inquiries@gov.ab.ca (mailto:HomeWarranty.inquiries@gov.ab.ca)
1.866.421.6929
Government

Page No.00418
(/BuilderConsole)

Part 1
Applicants
Part 2
Current Home
Part 3
New Home
Part 4
Part 5
Verification
Subcontractors who will be involved in building new the home.
Add new Contractor (/AuthorizationExemption/Create?builder=f89fce0b-d8e2-e411-9d1b-

005056b7097a&ContractorGrid-mode=insert)
Trade Business Name Address Phone

Page No.00419
K Previous H Save As Draft DU Cancel Changes Next }
The Subm it button above sends the online version o f yo ur application to the NHBPO, you w ill then view your
application.

You may pay o nline or off line, please S ubm it and proceed to the Fee Sum mary page.
Privacy Statem ent

The collection o f personal inform ation is necessary to support the New Home Buyer Protection Program. The
Privacy(FOlP) Act and w ill be m anaged in accordance with the privacy provisions in the Act. If you have
telephone to 1-866-421-6929.

10155- 102 Street
HS HomeWarranty.inquiries@gov.ab,ca (mailto:HomeWarranty.inquiries@gov.ab.ca)
V. 1.866.421.6929
Government
Page No.00420
(/BuilderConsole)

P a rti
Applicants
Part 2
C urrent Hom e
Part 3
N ew Hom e
Part 4
Part 5
Verification
Applicant(s)
D ate
of D river's Q u e s tio n n a ire
F irs t N am e L a s t N am e Birth L ic e n s e Phone C ell Fax E m ail C o m p le te ?
Mike O'Brian (7 8 0 ) am ber.fly@ m ailinator.com X

222
2222
Current Hom e
P h y s ic a l A d d re s s

Page No.00421
Mailing Address
First Name Last Name Date of Birth Phone Email
New Hom e
Unit Number
LINC
Civic Address
i
, Alberta
Lot/Block/Plan
C on tractors)
Trade Business Name Registered Address Phone
Warnings
• Questionaire (Part 1) is not com plete for: Mike O'Brian. Each applicant M U S T com plete the
questionaire.
• Applicant (Part 1) Mike O'Brian DoB should be in Y Y Y Y -M M -D D form at
• Applicant (Part 1) Mike O'Brian is missing date o f birth
• Applicant (Part 1) First N am e is missing
• Applicant (Part 1) Last N am e is missing
• Applicant (P art 1) Drivers License is missing
• Phone n u m b e r f o r (Part 1) is missing or not a valid phone num ber
• E m a il"" for (P art 1) is missing or not a valid Email
• Questionaire (Part 1) is not complete f o r : . Each applicant M U S T com plete the questionaire.
• Applicant (Part 1) DoB should be in Y Y Y Y -M M -D D form at
• Applicant (Part 1) is missing date o f birth
• Current Address (Part 2 ) Address Line 1 is missing
• Current Address (Part 2 ) City is missing
• Current Address (Part 2 ) Province is missing
• Current Address (Part 2 ) Postal C ode is missing
• N ew Hom e (P art 3) Municipality is missing
• N ew Hom e Location (Part 3 ) must have at least one of the legal descriptiosn is required:
A lberta 'MumcipaT Affairs Information Request 2015-R-0088
Page No.00422
Lot/B lock/P lan, A T S S tan da rd , or A T S N on -S ta n d a rd
A Please Note: Y o u r A p plica tion fo r O w n e r B u ild e r A u th o riz a tio n will n ot be c o n s id e re d co m p le te until

the o rig in a l d o w n lo a d a b le co m p le te d app lica tion , inclu ding the co m p le te d sw orn A ffid a v it o f E xecution,
has b ee n received by the N ew H om e B u yer P rotection O ffice.
K P re vio us H Save As D ra ft H C an cel C ha ng es
The Submit button above sendsthe online version of your application to the NHBPO, you will then view yourfee summary
page where you can confirm your fees and download the form so you may complete your application.
Payment Information
Privacy Statement
The collection of personal information is necessary to support the New Home Buyer Protection Program. The collection is
authorized under section 33(c) of the Alberta Freedom of information and Protection of Privacy(FOiP) Act and will be
managed in accordance with the privacy provisions in the Act. If you have questions regarding the collection of your
personal information, please send your inquiry to the New Home Buyer Protection Office,16th Floor,Commerce Place, 10155
- 102nd Street, Edmonton, AB, T5J 4L4 or telephone to 1-866-421-6929.

16th F loor, C o m m e rce Place
1 0 1 5 5 - 102 S tre et
E d m on ton , AB T 5J 4 L4 C anada
S H o m e W a rra n ty.ln q u irie s@ g o v.a b .ca {m a ilto :H o m e W a rra n ty .in q u irie s @ g o v .a b .c a )
© w w w .h o m e w a rra n ty .a lb e rta .c a (h ttp ://h o m e w a rra n ty .a lb e rta .c a /)
1 .8 6 6 .4 2 1 .6 9 2 9
Government

Page No.00423
,---------
Create Registration
Will you be b u ilding yo u r new ho u se with a warranty?

New Home Buye
Current User: amber rh No
Home Application Search £ Help me decide wnai type or application i need to make ) Brian (13080000000)
Owner Builder Console..... ........

All Applications Drafts Av.-ar.tng Payment f Apfi.cj Commence -<! O ccu p a - :.
+ Create Application
S3
Ct Search
j Actions A p p s t r o n lD ® Biififler ® P re p :! ® Municipals-, ® Location 0 Siatus ®
P f 15RF11f»&412
Mike O 3rian
f 13060000000)
Kate take Louise J2-25-423W 343 Approved
mu * I5 K F 1 165215
Mike O 3rtar.
(13OB0000C0D)
Kate Ryte> 4-£-34 Approved
o ✓ 15RF1165081
Mike 0 ‘5ron
{13OB0000000)
.
Kate Smoky Lake 23-23-23454345 Awaiting Payment
Mike O Brian
/ I5 R F 1 164863 Kate Andrew 12-12-156454 Awaiting Payment
u i i (13OBG000000I
□ □ ✓ W R EH :-651B
Mike O'Brian
(13QB000QC00)
Abee 321 Blast Ofl Wharf Approved
Mike O'Brian App

$ / ISA A in S& O O Champion 23 2432 Centre T 5 L 3E4 Awaiting Approval
(130B00000001 Authorization
Mika O'Brian Awaiting Warrant1,

/ 15RF1156S62 Alcomdale 7009 49A Avenue
(130600000001 Confirmation
MU ./ 1§HFt 158426
Mike O'Brian
(13060000000)
Kevin Payment
Test
Acadia Valley
10303 Fake Street NW
H0H OHO
Approved
f.ljke O Brian Lufcieon Lake Northern Sunrise

$ ✓ i£ H E 1124883 20-1-6121430 Cancelled
(13060000000) Band Count*
Mike O'Biian LuDicon Lake Ncnnem Sunrise

A ✓ 15ft£l 1247H 2C-1-8121430 Awaiting Approval

Page No.00424
\A

(/BuilderConsole)

Application information
Application ID
Status
f 1 . . .
Draft
Application Date
Builder Information
Builder Name
e
Mike O'Brian (13OB0000000) ▼
User Name
/ .....
Phone
/ ...............
Email
Page No.00425
Building ID
Project Name
Building Name
Construction Type
Building Type
Single-Family Detached ▼
Building Sub-type
Site-Built T
Municipality
Warranty
Warranty Provider
The Alberta New Home Warranty ▼
Request Validation
Building Location
Building Location

Page No.00426
Unit
Location

10155 - 102 Street
t- 1.866.421.6929
Government

Page No.00427
B u ild e r Name U ser Name Phone
; Mike O ’Bnan ; 13060000000) *
Email
Building information
Building 10 Project Name B u ild in g Name
C o nstructio n Type B u ild in g Type B u ild in g Sub-type
n sw construction * Smg!&-Far.;y c o a c h e d Site-Built
M u n ic ip a lity
T h is b u ild in g Is a co ndom inium or part ot a condom inium developm ent
T h is b u ild in g will have an additio nal 2

Request Validation
Warranty
Warranty Provider Millennium Insurance Corporation
Warranty Provider
Cancel
T he A ib e r.a N~v. H er e '.varra •> *
Building Location
Striding Locaton
Units
--;r
Unit Number Location Policy Number Retjisiraiion Uni! ID
Save amt Submil Save As Draft Cancel

Governrneni
Govi
G o v e rn m e n t of A lberta

Page No.00428
Construction Type Building Type Building Sub-type

New Construction - $-ngie-Family D etached T Sne- Built
’
Municipality
Thts building rs a cc Unil Location X
Tins building will hu A d d re s s Type
Civic Address T
W arranty
Warranty Provider © A d d new address
Tr.eAJberta New H en
Building Lccatior Lo t'B lo c k /P la n
© Add Lot/BiocfuPinn
Building Locafen
Lot Block Plan

Units
L e g a l D e s c rip tio n Type
Unit Number ATS Standard
tt Location
© A d d a t s Standard
| Save and Submit | Legal Subdivision Quarter Section Township Range Meridian
Cancel

Government of Alberta y$dh& rb(kj I Governmerv
iOJ5c- ■ 1D2 Street
Edmonton a b T5J 4L4 Canada
s
v*
C ! 554 411 5925

Page No.00429
(/BuilderConsole)

Part 1
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Primary Applicant

Name on Title*
Momo nn Title* Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00430
INCII I IC7 U l I I IU C
Authorized Person*
r' i i i
Authorized Person
Email Address*
t'
name@sample.com
Phone*
■■■■
Phone
Physical Address
Address Line 1*
Address Line 1
Address Line 2
Address Line 2
City*
City
Province
Postal Code*
Postal Code
Mailing Address
Current physical & mailing addresses are: Same o Different
Agreement*

Page No.00431
I understand that Pursuant to Section 3.1(8) of the Act, when this designation is registered on the
person referred to in Section 3.1 (3) of the Act.
H Save as Draft H Cancel Changes Next y
application.
To com plete your application, a printed copy o f the application signed by each a pp lica n t m ust be sent to the
4L4.
Payment Information
You m ay pay online or off line, please S ubm it and proceed to the Fee Sum mary page.
Privacy Statem ent

questions regarding the collection o f your personal inform ation, please send yo ur inquiry to the New Hom e
Buyer Protection Office, 16th Floor,Com m erce Place, 1015 5 -1 0 2 n d Street, Edm onton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

Page No.00432
10155- 102 Street
^ 1.866.421.6929
G overnm ent

Page No.00433
(/BuilderConsole)
A p p lica tio n fo r R ental E xem ption

Part 1
Applicant(s)
Part 2
Builder Information
Part 3
N e w Building
Part 4
Verification
Applicants Add C o-A pplicant
Co-Applicant1 Details ™ Rem ove C o-A pplicant
N a m e o n T it le *

Page No.00434
î c i i l i e u ii i iu c
Authorized Person*
t ..............
Authorized Person
Email Address*
t ■■■■ ■■
name@sample.com
Phone*
Phone
Physical Address
Address Line 1*
Address Line 1
Address Line 2
Address Line 2
City*
City
Province
Postal Code*
Postal Code
Mailing Address
Current physical & mailing addresses are: Same o Different
Agreement*

Page No.00435
[ understand that Pursuant to Section 3.1 (8) of the Act, when this designation is registered on the
H Save as Draft H Cancel Changes Next
application.
To com plete your application, a printed copy o f the application signed by each a pplicant m ust be s e n tto the
New Home Buyer Protection Office, 16th Floor, C om m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J
4L4.

You m ay pay online or off line, please Subm it and proceed to the Fee Sum m ary page.
Privacy Statem ent

telephone to 1-866-421-6929.

Page No.00436
10155 - 102 Street
V. 1.866.421.6929
G overnm ent

Page No.00437
(/BuilderConsole)

P a rti
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification

t -
Legal Business Name
Contact Person Legal Name*

/ "
Phone Number*
Phone Number
Email Address
t . . .
name@sample.com

Page No.00438
K Previous H Save as Draft ® Cancel Changes Next >
The S ubm it button above sends the online version o f your application to the NHBPO, you w ill then view your
fee sum m ary page w here you can confirm your fees and dow nload the form so you m ay complete your
application.
To com plete your application, a printed copy o f the application signed by each a pplicant must be sent to the
New Home Buyer Protection Office, 16th Floor, Com m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J
4L4.
Payment Information
You m ay pay online or o fflin e , please Subm it and proceed to the Fee Sum m ary page.
Privacy Statem ent

questions regarding the collection o f yo ur personal inform ation, please send your inquiry to the New Home
telephone to 1-866-421-6929.

10155 - 102 Street
V. 1.866.421.6929
G overnm ent

Page No.00439
(/BuilderConsole)

P a rti
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Building ID
r .......
Unique Building ID (Generated)
Project Name
t "
Project Name
Building Name
/
Building Name
Construction Type
/ i .

Page No.00440
Building Type
Multi-Family ▼
Building Sub-type
Rental ▼
Municipality
Select Municipality... ▼
Number of Buildings
Total Number of Units (all buildings)
Details
Building Address
LINC (separate multiple LINC's with a comma)

t ■■■ " .... ■ ■■■■ i S
LINC
What type of address best describes the building location?: © Civic Rural
Add Address (/RentalExemption/Create?builder=f89fce0b-d8e2-e411-9d1b-

005056b7097a&addrGrid-mode=insert)
Lot/Block/Plan
Add Lot/Block/Plan (/RentalExemption/Create?builder=f89fce0b-d8e2-e411-9d1b-


Page No.00441
Lot Block Plan
Legal Location Type

What type of address best describes the building location?: (•) ATS (Alberta Township System) Standard o
A T S (Alberta Tow nship S ystem ) Non-standard
Add ATS Standard (/RentalExemption/Create?bui!der=f89fce0b-d8e2-e411-9d1b-

005056b7097a&atsGrid-mode=insert)
< Previous H Save as Draft H Cancel Changes Next )
The Subm it button above sends the online version o f your application to the NHBPO, you w ill then view your
application.
To com plete yo ur application, a printed copy o f the application signed by each a pp lica n t m ust be sent to the
New Hom e Buyer Protection Office, 16th Floor, C om m erce Place, 10155 - 102nd Street, Edm onton, AB, T5J
4L4.
Payment Information
You m ay pay online or o fflin e , please S ubm it and proceed to the Fee Sum mary page.
Privacy Statement
questions regarding the collection o f your personal inform ation, please send your inq uiry to the New Home
telephone to 1-866-421-6929.


Page No.00442
10155 - 102 Street
S HomeWarranty.inquiries@gov.ab.ca {mailto:HomeWarranty.inquiries@gov.ab.ca)
V. 1.866.421.6929
G overnm ent

Page No.00443
(/BuilderConsole)

P arti
Applicant(s)
Part 2
Builder Information
Part 3
New Building
Part 4
Verification
Applicant(s)
Name On Title Authorized Person Email Phone Agreement Answered
Builder
Legal Business Name

Page No.00444
Phone Number
Email Address
New Building (Building ID:16BD1214414)
Project:
R ental: 2 Units, 1 Buildings
Municipality: Unknown
Warnings
• Builder Legal Business Name is required.
• Builder Contact Person Legal Name is required.
• Builder Phone Number is required.
• Builder Phone Number is not in a correct format.
• Municipality is missing
• A valid building location is require before the Rental Exemption can be submitted

Page No.00445
K Previous H Save as Draft H Cancel Changes
The S ubm it button above sends the online version o fy o u r application to the NHBPO, you w ill then view your
application.
To com plete your application, a printed copy o f the application signed by each a pplicant m ust be sent to the
4L4.
Payment Information
You m ay pay online or off line, please S ubm it and proceed to the Fee Sum mary page.
Privacy Statem ent

questions regarding the collection o fy o u r personal inform ation, please send your inquiry to the New Home
Buyer Protection Office,16th Floor,Com m erce Place, 10155 - 102nd Street, Edmonton, AB, T5J 4L4 or
telephone to 1-866-421-6929.

10155 - 102 Street
V. 1.866.421.6929
G overnm ent

Page No.00446

All A p p lic a tio n s D ra fts A w aiting P a y m e n t R e je c te d A p p ro v e d Com m encem ent O ccup an cy
+ C r e a te A p plicatio n + C r e a te R e n ta l E x e m p tio n
P a y S e le c te d Q. E n te r ap p licatio n ID Se a rch C R e s e t Filter
A ctio n s A p plicatio n ID (/B u ild e rC o n s o le G rid /G e tA IIB u ild e rR e g is tra tio n s ? B u ild e rA llR e g G rid -s o rt= R e g is tr:
$ </Payment/Paylrwoice?id=aS07d 104-32aO^511-8acd-005056af7e83) ✓ 1 5 R F 1 1 6 5 0 8 1 (/ B u iId e rC o n s o le / L o a d R e g is tr a tio n ? a p p N u m b e r= 1 5 R F 1 1 6 5 0 8 1 )
$ {/Payment/Paylnvaice?id=8e773473-32a0-e511-80cd-005056af7e83) f 15 R F 1 1 6 4 8 6 9 (/ B u i!d e r C o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r = 1 5 R F 1 1 6 4 8 6 9 )
$ (/Payment/Paylrwo!ce?id-8cae925e-5909-e511-9aa4-€05056b7097a)
f 15 A A 1 1 1 4 1 1 1 (/ B u ild e rC o n s o le / L o a d R e g is tra tio n ? a p p N u m b e r= 1 5 A A 1 1 1 4 1 1 1 )
S (/Pdf/PrintApp?id=1 5AA1114111)
r 1 - 3 of 3 item s

16th Flo o r, C o m m e r c e P la c e
1 0 1 5 5 - 1 0 2 S tre e t
Ed m o n to n , A B T 5 J 4 L 4 C a n a d a
S H o m e W a rra n ty .in q u irie s@ g o v .a b .ca (m aifto:H o m e W a rr a n ty .in q u irie s@ g o v .a b .c a )
9 w w w .h o m e w a rra n ty .a lb e rta .c a (http://hom ew arranty.alberta.ca/)
V 1 .8 6 6 .4 2 1 .6 9 2 9
j4dbe*bf^M .............. (http://alberta.ca/)

Page No.00447
Current User: amber tty
Home Applicator Search Builder Profile AccounlAdmintstraUon W o rkin g a s B u ild e r Mike CyBrian (13OB0000000) *
Registrations invoice 16IV 00650766

15RF1165081
B u ild e r Name: NH BPO B u ild e r ID:
Mike O'Brian O 3O B 0000000) 13060000000
R e g istra tio n Form ID: W arranty P ro v id e r
15RF1165081 The Alberta New Home Warranty Program
Date Subm itted:
2015-12-11
Property Type: Total Number of Units
Single-Fam ily Detached Site-Built 1
W arrantable C om m on Pro p erty? A d d itio n a l W arranty on B u ild in g E n ve lo p e ?
No No
Unit Information
R e g istra tio n Unit ID P h y s ica l A d d re s s L e g a l D e scn p tlo n LIN C Am ount
15RU1249258 23-23-23454345 $9500
1 Units $95.00
Invoice Total
Total:
S95 00
$ Pay Now i Print 0 Cancel

Page No.00448
A cco u n t NHBPO Paym entslIAT is in test m ode
Name: Mike O'Brian (13OB0000000)

Phone Number:
Address Line 1:
Address Line 2:
City:
Province: Alberta ▼
Postal Code:
Country: Canada T
Email: amberfly@gmail.com
ID
Paym ent processing
pow ered b y T D
VISA
Amount: $95.00 CAD
Name on card:
Credit Card Type: VISA T
Credit Card Number:

Expiration Date: 01 ▼ / 2015 T
Submit Payment

Page No.00449

+ Create Application + Create Rental Exemption
*S Pay Selected Q. Enter application ID Search O Reset Filter
Actions Application ID {/BuilderConsoleGrid/GetAIIBuilderRegistrations?BuilderAIIRegGrid-sort=Re
^ r(/W a rra n ty C o m rn e n ce m e n t? id = 9 6 a 7 B a 1 9 -3 3 a 0 -e 5 1 1 -8 0 cd -0 0 5 0 5 6 af7 e 8 3 )

/1 5 R F 1 1 65412 (/Bui!derConsole/LoadRegistration?appNumber=15RF1165412)
6 (/P d & P rin tC e rt? id = 1 5R F 1 1 6 5 4 1 2 )
# (/W arra n ty C o m m an ce m e n l7 ld = B e d 9 3 b 9 b -3 2 a 0 -a 5 1 1 -8 0 cd -0 0 5 0 5 6 af7 B 8 3 )

✓ 15R F1165215 (/Bui1derConsole/LoadRegistration?appNumber=15RF1165215)
& (/P d f/P rin tC e rt? id = 1 5 R F 1 1 6 5 2 15)
ft (/W arrantyC om m encern0nt?ld=76Sb6O cf-df83-s511-8Q c9-O O 5O 56af7eB3)

y 15R F1158426 (/Builde;Consoie/LoadRegistration?appNumber=15R F1158426}
* (/Pdf/PrintCert?id=15RF1158426)
^ (/W a rra n ty C o m m e n ce m e n t? id = a 2 b 0 7 a 2 2 -9 4 2 5 -e 5 1 1 -6 0 8 7 -0 0 5 0 5 6 b 7 0 9 7 a )
y 1 5R F1146524 (/Bui!derConsole/LoadRegistration?appNumber=15RF1146524}
* (/P d f/Prin tC a rt7 id = 15 R F1 1 4 6 5 2 4 )
A (/W a rra n ty C o m m e n ce m e n t7 id = d e c 0 a 0 6 7 -d 3 2 0 -e 5 1 1 -8 0 B 7 -0 0 5 0 5 6 b 7 0 9 7 a )
f 15RF1144920 (/BuilderConsole/LoadRegistration?appNumber=15RF1144920)
f t (/Pdf/PrintCert?id=15 R F 11 4 4 9 2 0 )
■ ^ (/W a rran ty C o m m e n ce m e n t? id = 5 cb 2 4 4 5 a ‘6 f0 8 -e 5 1 1 " 9 a a 4 ‘ Q 05056b7Q 97a)

✓ 15RF1130286 {/BuilderConsole/LoadRegistration?appNumber=15RF1130286)
f t (/P df/Prin tC e rt?id = 1 5R F11 3 D 28 6 )
0 1 - 6 o f 6 items

10155- 102 Street
V. 1.866.421.6929
y & ib e r b f ij r (http://alberta.ca/)

Page No.00450
C u rrent U s e r noir res
Hom e Application S e a rc h Builder Profile Acco u nt Adm ifiss’.ranon W o rk in g a s B u ild e r M o re N o il

• o
R e g is tra tio n In fo rm a tio n
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t6th Floor, Commerce Place

10 15 5 - 102 Street
Edmonton. A9 T 5 J 4L4 Canada
B N H BPS access-,§gov at) ca
O wwwncmewarranry aroerta ca
C 1 855.421 6929

Page No.00451

+ Create Application + Create Rental Exemption
Pay Selected Q, Enter application ID Search C Reset Filter
Actions Application ID (/BuilderConsoleGrid/GetAIISuilderRegistrations?BuilderAIIRegGrid-sort=RegistrationNo.
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& (/ P d fjP r in tA p p ? id = 1 5 R E 1 1 2 6 5 1 6 ) y 15RE1126516 (/Bui[derConsole/LoadRegistration?appNumber=15RE1126516)
$ (/P d f/P rin tC e rt? id = 1 5 R E 1 1 2 6 5 1 6 )
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S (/PdPPrintA p p ?id = 15 A A 1 1 1 67 4 1 } y 15AA1116741 (/BuilderConsole/LoadRegistration?appNumber=15AA1116741)
y 15AA1116625 (/BuilderConsole/LoadRegistration?appNumber=15AA1116625)
y 15AA1116295 (/BuilderConsole/LoadRegistration?appNumber=15AA11 16295)
A (/Pd1/PrintApp7id=15A A11 1 6 1 3 4 ) y 15AA1116134 (/BuilderConsole/LoadRegistration?appNumber=15AA1116134)
f t (/P df/Prin tCe rt7 id -1 5 A A 1 1 1 6 134)
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£ (/Pdf/PrintApp?id=15 A A 1 1 1 6 0 7 1) y 15AA1116071 (/BuilderConsole/LoadRegistration?appNumber=15AA1116071)
$ {IPd 0 P rin tC e rt7 id = 1 5 A A 1 1 1 6 0 7 1 )
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£ (/Pdf/Prin1App?id=15 A A 1 1 1 5 9 8 9 ) y 1SAA1115989 (/BuilderConsole/LoadRegistration?appNumber=15AA1115989)
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& (/P df/Prin tA p p ?id = 15 A A 1 1 15 8 7 6 ) y 15AA1115876 (/BuilderConsole/LoadRegistration?appNumber=15AA1115876)
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£ (/P dO P rin lCe rt?id= 15 R E 1 1 2 3 2 3 0 )
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Page No.00452
1 - 10 of 15 items

1 0 1 5 5 -1 0 2 Street
!S HomeWarranty.inquiries@gov.ab.ca (maitto;HomeWarranty.inquiries@gov,ab.ca)
Q www.hom ewarranty.alberta.ca(http://homewarr 3 nty.3 lberta.ca/)
V. 1.066.421.6929
Government

Page No.00453
(/BuilderConsole)
Current User: a m b e r fly
Occupancy
Builder:
Mike O'Brian (13080000000)
Authorization A pplication Number:
15RE1126516
Project:
321-Blast Off Amarbir

15RU1244876 01/05/2016 01/06/2016
Wharf Randhawa
1 1 -1 of 1 items
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10155- 102 Street
t . 1.866.421.6929

Page No.00454
Government

Page No.00455
Cu rrent u ser: amber fly
H om e A pplication S e a rc h Builder Profile Account Adm inistration w o r k in g a s B u ild e r M ike O ’Brian (ISOBOOGOOQO i ▼
Occupancy
B u ild e r U n it O c c u p a n c y
(.like 0 Brian {13OB000000Q)
D a le 1 15 2016
N o te s :
Registration unit ID © Civic Address © Reported Date © Actions
date entered deleted
15RU1244376 3 2 1-Blast Off Wharf 01/05/2016 ©
1 I of t items
£3 Save Cancel Save Cancel

1 0155- 102 Streel
Edmonton A S T 5 J 4L4 Canada
S HomeWarranly inqumes@gov ab ca
O www.hQrrtewarranty alberta ca
V. 1 866 421 6929

Page No.00456
Project Number
Town of High River Recovery Funding
[Insert]
Grant Application Policy Review Form 2015-16 Intake
Project Name: [Insert Project Name] Grant Component Information:
Recovery Element Supported

□ Long-Term Recovery Support
□ People □ Economy □ Environment □ Reconstruction
REVIEWER ASSESSMENT
Please answer the following questions and provide details in Reviewer Comments, if necessary:
□ Yes □ No 1. Does the project overlap with policy and programing of another ministry?
!f ‘Yes', please complete the Cross-Ministry Assessment at the bottom of this form.
□ Yes □ No 2. Was the project identified in the 2013-17 Capital Plan prior to the 2013 floods?
□ Yes □ No 3. Is the funding proposed to be used in a way that could create long-term dependencies or
support ongoing core (non-recovery) operating costs? if ‘Yes', please detail rationale in Reviewer
Comments.
□ Yes □ No 4. Is the primary intended outcome of the project beautification or cosmetic in nature?
□ Yes □ No 5. Overall, does the project align with the intent of the Long-Term Recovery Plan to return the
town to a state where it has the capacity to function normally with routine levels of provincial
support and sustain itself into the future? Describe in the Reviewer Comments. If 'No', matter should be
tabled at weekly meeting with Grant Program Delivery.
Assigned Reviewer: [Insert Name]____________________ Date Recommended: [mm/dd/yy]_____
Reviewer Assessment: □ Proceed with Detailed Review □ Do Not Proceed with Detailed Review
Reviewer Comments:
Please note any conversations reviewer has had with the Town of High River as required.
[Insert Comments]
Cross-M inistry Assessm ent

Instructions: Complete for projects where possible overlap with policy and programing in another ministries
or divisions has been identified. Records of consultation through the Cross-Ministry Working Group should be
retained to support funding decisions. Grant Program Delivery should be copied on all applications forwarded
to members of the Cross-Ministry Working Group for review,
Other Ministries/Divisions Consulted: [Insert Ministry/Division]
Significant Concerns Identified? □ Yes* □ No

*If ‘Yes' provide details in Cross-Ministry Assessment Comment.
Date Confirmation to Proceed Received : [Insert Date]
Cross-M inistry Assessm ent Comments:
[Insert Comments]
"" Page' No.00457
Town of High River Long-Term Recovery Funding
Cross-Ministry Working Group Review Form for 2015-16 Intake Government
Ministry: [Insert Ministry Name]

Area: [Insert Division or Branch Name]
Project Number
Project Name: [Insert Project Name] [Insert]
Reviewer Assessment
□ Yes □ No 1. is funding for this project already being provided by your ministry that is not
noted on the application form?
□ Yes □ No 2. Does another grant program with available budget dollars exist that would be
a more appropriate funding source for this project?
□ Yes □ No 3. Do you have any significant concerns regarding how this project aligns with
existing ministry policy interests and objectives?
Reviewer Assessment: HD No Policy or Funding Issues Identified □ Policy or Funding Issues Identified
Reviewer Comments:
Please provide supporting information if you have answered 'Yes' to any o f the questions in the Reviewer Assessment as well as any other general
comments regarding the project and whether it should proceed for further review by Municipal Affairs,
[Insert Comments]
Project Number
Project Name: [Insert Project Name] [Insert]
Reviewer Assessment
□ Yes □ No 1. Is funding for this project already being provided by your ministry that is not
noted on the application form?
□ Yes □ No 2. Does another grant program with available budget dollars exist that would be
a more appropriate funding source for this project?
□ Yes □ No 3. Do you have any significant concerns regarding how this project aligns with
existing ministry policy interests and objectives?
Reviewer Assessment: HD No Policy or Funding Issues Identified HD Policy or Funding Issues Identified
Reviewer Comments:
Please provide supporting information if you have answered ‘Yes' to any o f the questions in the Reviewer Assessment as well as any other general
comments regarding the project and whether it should proceed for further review by Municipal Affairs.
Page 1 of 2
Page No.00458
[Insert Comments]
Review of th ese applications w as conducted by:
Assigned Reviewer: [Insert Name]_______________ Date Review Completed: [mm/dd/yy]
Title: [Insert Title ]________________
je2of2
Page No.00459
Village of Minburn
Viability Review
Stakeholder Engagement
Workbook
How to Provide Your Input
S takeh o ld er in p u t is due on or b efo re August 8, 2 0 1 4
Ways to provide the stakeholder input:

1. Drop off the workbook today at the meeting
2. Email scanned copy of stakeholder input form
to viabilitvreview@gov.ab.ca
3. Fax stakeholder input form to: 780-420-1016
4. Mail the completed workbook to:
Attn: Village of Minburn Viability Review
Municipal Services and Legislation Division
17th Floor-Commerce Place
10155 - 102 Street NW

Page No.00460
Discussion Questions
l.W h a t is important to you about being a village?
2. What municipal services are important to you?
3. How could these municipal services be funded

in the future?

Page No.00461
Discussion Questions
4. Do you see potential for growth in Minburn?
5. Based on your knowledge and the information

provided in the Initial Findings Report, do you
believe that the Village of Minburn is a viable
municipality?
6. What else does the Viability Review Team

need to hear?

Page No.00462
Thank you
for participating
and providing
your valuable input to the
Village of Minburn
Viability Review Team.

Page No.00463
Village of Cremona Viability Review
Stakeholder Input Form
A viability review has been initiated for the Village of Cremona as a result of a petition received from village
electors requesting the Minister of Municipal Affairs to undertake a dissolution study. The dissolution study is
being undertaken in the form of a viability review. If you would like to provide input to the Village of Cremona
Viability Review Team as a resident, property owner, or community stakeholder, please complete this form and
return it to Municipal Affairs by May 10, 2013.
1. Are you a resident of the Village of Cremona?
□ Yes □ No
2. Do you operate a business in the Village of Cremona?
□ Yes □ No
3. What is your level of satisfaction with the following in the Village of Cremona?
Rating
issue or Topic Rate each topic with 1 as very
dissatisfied and 5 as very satisfied
Bylaw enforcement 1 2 3 4 5
Council communication with residents 1 2 3 4 5
Culture and recreation programs and services 1 2 3 4 5
Fire and emergency services 1 2 3 4 5
Infrastructure (e.g. roads, sidewalks, water) 1 2 3 4 5
Planning and development 1 2 3 4 5
Property taxes 1 2 3 4 5
Quality of life in the community 1 2 3 4 5
Road maintenance and snow removal 1 2 3 4 5
Utility charges 1 2 3 4 5
W aste management (garbage and recycling) services 1 2 3 4 5
W ater and sewer services 1 2 3 4 5
4. What is your level of satisfaction with the following in the Village of Cremona?
Rating
Issue or Topic Rate each topic with 1 as very
dissatisfied and 5 as very satisfied
How council cooperates with other municipalities 1 2 3 4 5
How the village manages its finances and budget 1 2 3 4 5
How council and administration manages the village 1 2 3 4 5
Your opportunity to provide input to your municipality 1 2 3 4 5
How village business is conducted in an open and public
1 2 3 4 5
manner
Please remember to complete page two of this form.
Page 1 of 2
Page No.00464
Village of Cremona Viability Review
Stakeholder Input Form
5. Do you support that Alberta Municipal Affairs should conduct a viability review of the Village of
Cremona at this time?
□ Yes □ No □ I am undecided at this time
6. Do you wish to provide any additional comments to the viability review team?
Please return the completed form to Municipal Affairs using one of the following methods:
- By email: viabilitvreview@Qov.ab.ca
- By fax: 780-420-1016, Attn: Cremona Viability Review
- By mail: Attn: Cremona Viability Review, Alberta Municipal Affairs, Municipal Services Branch,
17thFloor - Commerce Place, 10155-102 Street NW, Edmonton, AB, T5J 4L4.
Page 2 of 2
Page No.00465
Government Regional Services Commission Requests
Office Use Only
Municipal File Number
REGIONAL SERVICES COMMISSION REQUESTS
INSTRUCTIONS: Use this form for establishment/disestablishment, regulation amendments, sale of assets, and ministerial approvals with respect to
regional services commissions. Applicants wilt be required to provide different information depending on the type of request. Applicants should first
familiarize themselves with the RSC flowcharts available here. Electronic or paper copies can be submitted, but only electronic users will benefit from the
streamlined process as well as some of the automatically calculated and populated fields. Please note that for board appointment bylaw approvals, an
originally signed copy must be submitted by mail as the original is required for the Minister's signature.
The personal information on this form is being collected for establishment/disestablishment, regulation amendments, sale of assets, and ministerial
approvals with respect to regional services commissions. Its collection is authorized under section 33(c) of the Freedom of Information and Protection of
Privacy (FOIP) Act. All personal information collected wilt be managed in accordance with the privacy provisions of the FOIP Act. If you have any questions
regarding the cotlection of this personal information, please contact the Municipal Collaboration Unit by telephone at 780-427-2225 (for callers outside of
Edmonton, you may call toll-free by dialling 310-0000, then 780-427-2225), by email at municipal.sustainability@gov.ab.ca, or by writing to the Director,
Municipal Collaboration Unit, Municipal Affairs, 17th Floor, Commerce Place, 10155 - 102 Avenue NW, Edmonton, AB, T5J 4L4.
Applicant Information
Legal Name of Regional Services Commission (as per Commission Regulation)
List any other names that the Commission may be operating by

....
Name of Commission Manager or Managing Partner
Commission Manager's Telephone Number (Office) Commission Manager's Telephone Number (Cell)
Commission Manager's Email Address Mailing Address
Postal Code Name of Commission Chair Email Address of Commission Chair
Details of Request
2 Add m em ber
2 Rem ove m em ber
' 2 Change the nam e o f the com m ission
2 Change the services the com m ission is authorized to provide
~2 M inisterial approval to provide services outside com m ission m em ber boundaries
22 M inisterial approval of board appointm ents bylaw
2 Establish a com m ission
Disestablish a com m ission
] ] Sale o f assets
| | O ther
HRMA11028 (2015/09) Alberta Municipal Affairs Information Request 20a15-R-§P8®

Page No.00466
Have you attached the required documentation to your request? Q Yes Q No
Comments
If applicable, please indicate the date you would like this change to be effective (yyyy-mm-dd)
Have you already contacted a member of the Municipal Sustainability Team with respect to your request? If so, who did you speak with?
Will you be submitting any other requests for changes? If so, please describe.
Is there any other information that you believe is relevant to your request?
Application Certification
Date Commission Manager or Duly-Authorized Signing Officer Commission Manager or Duly-Authorized Signing Officer
(yyyy-mm-dd) (Print Name) (Signature)
I certify that the information contained in this application is correct.
Municipal Affairs: Municipal Services and Legislation Division
Commission Profiles
Municipal Officials Search
Submission
Submit the application via mail or email (email is preferred unless you are submitting a board appointments bylaw for ministerial approval). Applicants opting
to submit by email may make their submission from this page using the button below or save a working copy for future submission. Applicants opting to
submit by mail should use the print button below.
Use only one method of submission.
Ensure that all supporting documentation accompanies this form.
Mailing Address: E-mail:

Municipal Affairs municipal.sustainability@gov,ab.ca
Municipal Collaboration Unit
17th Floor, 10155-102 Street
Edmonton AB
T5J 4L4
HRMA11028 (2015/09) Alberta Municipal Affairs Information Request 2015'R'0088

Page No.00467
Municipal Officials Directory Update
Government for Regional Services Commissions, Local Government Associations and Other Organizations
This information is being collected for the purposes o f updating the Municipal Officials Directory and will be managed in compliance with the Freedom of Information and
Protection o f Privacy Act. If you have any questions concerning the collection o f this information, please contact Information Services by telephone at 780-427-2225. (For
callers'outside o f Edmonton, you may call toll-free by dialling 310-0000, then 780-427-2225), by email at las, updateicbaov. ab. ca. or by writing to the Director, Municipal
Collaboration Unit, Municipal Affairs, 17th Floor, Commerce Place, 10155 - 1 0 2 Avenue NW, Edmonton, AB, T5J4L4.
Stakeholder Name Municipal Code
Stakeholder Information
Mailing Address City Postal Code
Location Address, if different than mailing address City Postal Code
Telephone Number Fax Number Stakeholder Email Address (General)
Stakeholder Website Address (e.g. www.stakeholderwebsite.ca etc)
Contacts - (e.g. Chairperson/President, Vice Chairperson/Vice President, Manager/Chief Administrative Officer, FOIP Contact, Financial Contact)
Salutation First Name Last Name
-Select-
Working Title Role
- Select -
Business Email Address
Name of Person Completing This Form Position of Person Completing This Form Date (yyyy-mm-dd)
LGS0122 (2015/01)
Page No.00468
Municipal Officials Directory Update
^ ib e r b f i j i Government
________________ for Municipalities
This information is being collected for the purposes o f updating the Municipal Officials Directory and will be managed in compliance with the Freedom o f Information and Protection
of Privacy Act. If you have any questions concerning the collection of this information, please contact Information Services by telephone at 780-427-2225. (For callers outside of
Edmonton, you m ay call toll-free by dialing 310-0000, then 780-427-2225), by email a t Igs. update(8)aov. ab. ca. or by writing to the Director, Municipal Collaboration Unit, 17th F lo o r-
Commerce Place, 1 0 1 5 5 - 102 Avenue NW, Edmonton, AB, T5J 4L4.
Name of Municipality Municipal Code
Organizational Meeting Updates (Change in Mayor, Reeve or Councillor)

This form is n o t to b e u s e d fo r B y-elections.
Salutation Official Title (CEO only) First Name Last Name

-Select- -Select-
Role Working Title Business Email Address
-Select-
Administrative Contact/Designated Officers (e.g. Chief Administrative Officer, FOIP Contact, Financial Contact, Other Official)
C o n tact inform ation fo r C h ie f A d m in istrative O ffic e r a n d the F O iP C o n ta c t is a legislative requ irem en t.
Salutation First Name Last Name
-Select-
Role Working Title Business Email Address
-Select-
Municipal Information
Mailing Address City Postal Code
Location Address, if different from mailing address City Postal Code
Phone Number Fax Number Municipal W eb Site Address (e .g . w w w .m u n ic ip a lw e b s ite .c a e tc .) General Email Address .
Name of Person Completing This Form Position of Person Completing This Form Date ( y y y y -m m -d d )
LGS0121 (2015/01) Alberta Municipal Affairs Information ReqPag £ d1<5f R-0088

Page No.00469
Schedule 1
Government
Oath of Census Co-ordinator
Determination of Population Regulation
Alberta Regulation 63/2001
The personal information on this form is being collected under the authority of the M u n ic ip a l G o v e r n m e n t A c t will be used for the purposes of
that Act. It is protected by the privacy provisions of the F r e e d o m o f In fo r m a tio n a n d P r o te c tio n o f P r iv a c y A c t. If you have any questions about
the collection, contact: (title and business phone of the responsible official)
Municipal Authority_____________________________________________________ ■ Province of Alberta.
Municipal Census D a te ______________________
I , ____________________________________________________________ , of
Name of Person taking Oath
, appointed Census Co-ordinator for

Residential Address
solemnly swear/affirm
Municipality Name
THAT I will act diligently, faithfully and to the best of my ability in my capacity as Census Co-ordinator,
THAT I will not, without authority, disclose or make known any information that comes to my knowledge by reason of my activities
as a Census Co-ordinator; and
THAT I will supervise the municipal census and all census enumerators to the best of my ability and in accordance with the
Municipal Census Manual approved by the Minister and published by the department.
SW O R N/AFFIRM ED before me on
Signature of Person taking Oath

at , Alberta.
Signature of Commissioner for Oaths
IT IS AN OFFENCE TO SIGN A FALSE AFFIDAVIT
LGS0004 (2013/03) Alberta Municipal Affairs Information ft$,20?3tj2915t'.RrOO88

. Page No.00470
Schedule 2
Government
Statement of Census Enumeration
The personal information on this form is being collected under the authority of the M u n ic ip a l G o v e r n m e n t A c t will be used for the purposes of
that Act. It is protected by the privacy provisions of the F r e e d o m o f In fo r m a tio n a n d P r o te c tio n o f P r iv a c y A c t. If you have any questions about
the collection, contact: (title and business phone of the responsible official)
Municipal Authority_____________________________________________________ , Province of Alberta.
I, _________________________________ , of
appointed census enumerator for

Residential Address
solemnly state
Municipality Name
THAT I will act diligently, faithfully and to the best of my ability in my capacity as census enumerator;
THAT I will not, without authority, disclose or make known any information that comes to my knowledge by
reason of my activities as a census enumerator; and
THAT I will carry out the census of the area to which I have been assigned to the best of my ability and in
accordance with the Municipal Census Manual approved by the Minister and published by the department.
Date Signature of Census Enumerator
IT IS AN OFFENCE TO SIGN A FALSE AFFIDAVIT
LGS0005 (2013/03) Alberta Municipal Affairs Information Request S0rt6dR20088

Page No.00471
Schedule 3
Government
Shadow Population Verification Form
Municipal Authority_________________________ , Province of Alberta.
Municipal Census Date
I , _________________________________ , of
, appointed designated officer for

Residential Address
Municipality Name
THAT I am t h e _____
Designated Officer
of the municipality of
Municipality Name
THAT the date chosen as the municipal census date for this municipality was .
Date
T H A T a count of the shadow population completed o n _______________________ discloses that the total number of temporary
Date
residents who are employed by an industrial or commercial establishment in the municipality for a minimum of 30 days within
the municipal census year is _______________ .

Total Shadow
Population
SW OR N/AFFIRM ED before me on
Signature of Designated Officer

at Alberta.
LGS0006 (2013/03) Alberta Municipal Affairs

m ^ 0088
'age No.00472
Schedule 4
^ 4 iberbfijM Government
Municipal Census Form
Municipal Authority__________________________ , Province of Alberta.
I, ________________________________________________________________________________ , of
, appointed designated officer for

Residential Address
Municipality Name
THAT I am the designated officer of the municipality of

Municipality Name
THAT the date chosen as the municipal census date for this municipality was .
Date
T H A T a municipal census completed on ____________________________discloses that the total number of individuals

Date
whose usual residence is in this municipality i s _______________ .

Total Population
THAT the Municipal Census Field Report attached below is accurate and complete to the best of my knowledge.
SW O R N/AFFIRM ED before me on
Signature of Designated Officer

at , Alberta.
Municipal Census Field Report
Field Report for the census of

Year Municipality
Total population
Total count of dwellings
Total number of non-contacted dwellings
L G S 0 0 0 7 (2013/03) Alberta Municipal Affairs Information

Authorization for Returning Officer,
Deputy or Constable To Vote
At An Advance Vote
Local A uthorities Election A ct
(S ections 8 3 (3 ))
Local Jurisdiction: Province of Alberta
To Deputy Returning Officer
, having been duly authorized and appointed

(Name of Officer)
as an Officer in the Local Authorities Election on. is
authorized to cast his /her vote at an advance vote, and this shall be your authority
for allowing such vote to be cast.
(Signature o f Returning Officer)
MA0768 (2007/04)

Page No.00474
Authorization for Returning Officer,
Deputy or Constable Voting At
Assigned Station
L o c a l A uthorities E lection A c t (Section 83(1))
Local Jurisdiction: Province of Alberta
To Deputy Returning Officer
_____________________________________ , having been duly authorized and appointed

(Name of Officer) a
as an Officer in the Local Authorities Election on______________________________ , is
authorized to cast his/her vote at an assigned station, and this shall be your authority
for allowing such vote to be cast.
(Signature of Returning Officer)
LGS 0767 (2007/04)

Page No.00475
Affidavit of Witness for
Destruction of Election Materials
Local A uthorities Election A ct
(S ection 1 0 1 )
I, .solemnly swear (affirm) that on
____________________________________ , I witnessed the destruction of the content of the ballot
boxes used in the election held on____________________________________________ , at the
____________________________________ o f _______________________________________ .
I, .solemnly swear (affirm) that on
____________________________________ , I witnessed the destruction of the content ofthe ballot
boxes used in the election held on____________________________________________ , at the
____________________________________ o f _______________________________________ .
SWORN(AFFIRMED) before me
at the--------------- of_____________
(Signature of Person Taking Oath)

in the Province of Alberta
this____ day of____________ 20

(Signature of Person Taking Oath)
MA0769 (2007/04)

Page No.00476
Government Candidates Nomination Information
Name of Municipality Election Type □ General □ By-election Election Date
(yyyy-mm-dd)
C a n d id a te In fo rm a tio n (Section 28(6) of the Local Authorities Election Act and Section 577 of the Municipal Government Act)
W a rd / F em ale M ale First N am e Last N a m e M ailing A ddress o f Candidate Postal C o de A cclaim ed Incum bent Nom inated
Division (X ) (X ) ( e g . B o x N o / S t r e e t / P R , C it y /T o w n ) Position
N um ber
□ □
□ □
□ □
□ □
□ □
□ □
□ □
□ □
□ □
□ □
□ □
□ □
Name of Candidates for the Chief Elected Official (if applicable)
□ □
□ □
□ □
□ □
□ □
Is yo u r C h ief Elected O fficial elected at large? □ Yes Q No Is y o u r m unicipality providing fo r a vote on a question o r bylaw ? Q Yes Q No
Is yo u r m unicipality providing fo r voting by special ballot? □ Yes Q No
Returning Officer Information

Title Name (First,Last) Telephone Number Fax Number Email:
The personal information on this form is being collected to support the determination of provincial population and is authorized under the
Determination of Population Regulation, made under the Municipal Government A ct The personal information will be managed in compliance
with the privacy provisions of the Freedom of information and Protection of Privacy Act. If you have any questions concerning the collection of
this personal information, please contact Capacity Building at 780-427-2225 or by writing to the Director, Capacity Building, 17th Floor,
Commerce Place, Edmonton, Alberta T5J 4L4. (Outside of Edmonton call 310-0000 to be connected toll free.) Signature o f Returning Officer
MA1332 (2010/05) Alberta Municipal Affairs Information RequeSts2015-R-0088

Page No.00477
Government of Alberta Official Election Results
Municipal Affairs (section 97 o f the Local Authorities Election Act and section 577
of the Municipal Government Act)
Name of Municipality
D ivision/ F e m a le M a le Mailing Address of Candidate Postal Code N um ber of If d eclared If

Nam es of a II Candidates
W a rd check check V o te s R ec e iv e d elected In cu m b en t
a s they appear on the ballot for Councillors ( e .g . B o x N o / S t r e e t / R R , C it y /T o w n ) (A = A cc la im e d ) c h e c k(X ) c h e c k(X )
N um ber (X ) (X )
o r lis t nam e s if ac claim e d
First Name Last Name
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
Name of Candidates for the Chief Elected Official (If appliesable)
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
Number of Actual Voters ____________ I certify that this is a true statement of the results of the election held on ______________
Date of Election
Number of Eligible Voters ____________ _________________________________________________ __________________________________

Signature of Returning Officer Date
The returning officer shall forward this information to the Deputy Minister of Alberta Municipal Affairs on the 4th day after Election Day.
MA0120 (2010/05)
Page No.00478
Government Request for
of Alberta ■ m ilenet Internal milenet Access
COMPLETE A SEPARATE FORM FOR EACH

milenet APPLICATION BEING REQUESTED
SECTION 1 - EMPLOYEE
Name of Employee Requesting Access Title
Branch/Unit Telephone Number
R e q u e s t a c ce ss to m ile n e t application (choose one only):
□ AERIS □ ASSET O GMAS □ MFIS □ SIMS
□ ALPAS □ FERS □ METS □ RSLTS □ MEMPS
T y p e o f ac ce ss required (choose one only): I I R ead | | W rite
P ro vid e a b rief description o f yo u r business re q u ire m en t to ac c e s s th e a b o v e application:
Employee Signature Date (y y y y /m m /d d )
SECTION 2 - MANAGER/SUPERVISOR* SECTION 3 - SYSTEM OWNER

Approved: Q Yes O No Approved: O Yes Q No
Name of Manager/Supervisor Name of System Owner
Title of Manager/Supervisor Title of System Owner
Signature of Manager/Supervisor Signature of System Owner
Date Date
*NOTE: Manager/Supervisor must notify the System Owner when this user no longer requires access.
SECTION 4 -APPL CATION ADMIN STRATOR

Application Admin. ID Employee ID Temporary Password Application Role Date Added Date Removed (mm/dd/yyyy)
(mm/dd/yyyy)
For further information, please contact the milenet Security Administrator at 780-422-8074.
LGS1309 (2010/06)
Page No.00479
Linear Property Assessment Request for Information - Cable Distributions
http://www.municipalaffairs.alberta.ca/audio/RFI Report Declaration Form-CBL.pdf
Linear Property Assessment Request for Information - Electric Power Generation

http://www.municipalaffairs.alberta.ca/documents/LGS/RFi Report Declaration Form-EPG.pdf
Linear Property Assessment Request for Information - Electric Power Transmission and Distribution
http://www.municipalaffairs.alberta.ca/documents/LGS/RFI Report Declaration Form-ELE.pdf
Linear Property Assessment Request for Information - Gas Distribution

http://www.municipalaffairs.alberta.ca/documents/LGS/RFI Report Declaration Form-GDP.pdf
Linear Property Assessment Request for Information - Pipelines

http://www.municipalaffairs.aiberta.ca/documents/LGS/RFI Report Declaration Form-PL.pdf
Linear Property Assessment Request for Information - Telecommunication Carriers

http://www.municipaiaffairs.alberta.ca/audio/RFI Report Deciaration Form-TEL.pdf
Linear Property Assessment Request for Information - Wells

http://www.municipalaffairs.alberta.ca/documents/LGS/RFI Report Declaration Form-WLSK.pdf
[Further information on the Linear Property Assessment RFI process is available herel
Linear Property ePost Connect

http://www.municipaiaffairs.aiberta.ca/documents/as/Participation Agreement Instructions Forms M
ay 26.pdf
Participation Agreement Form (page 3)
Participation Agreement Form - Tax Agent (page 4)
Annual Assessor Declarations

http://www.municipalaffairs.aiberta.ca/documents/as/2015 Recording and Reporting Information fo
r Assessment Audit and Equalized Assessment.pdf
Annual Return Declaration (page 161)
Supplementary Assessment Declaration (page 163)
Assessment Revisions Declaration (page 164)
Annual Declaration - Linear Property Assessor (page 166)
Assessment Review Board Complaint Form

http://www.m unidpalaffairs.alberta.ca/d 0 cuments/a 5 /ARBC0 mpiaintF 0 rm.pdf
Assessment Complaints Agent Authorization Form

http://www.municipalaffairs.alberta.ca/documents/as/Aeent Authorization Final LGS1405.pdf
Compliance Review Form

http://www.municipalaffairs.alberta.ca/documents/as/Compliance Review Form LGS140S.pdf
Property Tax Exemption Forms

http://www.municipalaffairs.alberta.ca/documents/as/COPTER guide forms.pdf

Page No.00480
Municipal Sustainability Initiative (MSI)
^4dberbf>Ji Government 2014 Capital Program
Statement of Funding and Expenditures (SFE)
Municipality Office Use Only

Municipal Code SFE#
• Due Date - The due date for submitting the 2014 SFE to Alberta Municipal • 201S Allocation - The 2015 Funding Allocation will not be released until the 2013 SFE is certified, the 2014 SFE is received,
Affairs is May 1,2015. sufficient 2015 Capital Project Applications submitted, and the 2009 allocation has been reported as fully expended.
MSI Capital Funding Available
Total Funding C a rry-F orw a rd from P revio u s Y e a r (A )
Funding Allocation in Reporting Y e a r (B )
Credit Items (including Incom e E a rned ) in Reporting Y e a r (C )
Tota l Funding A vailable in Reporting Y e a r (A + B + C ) 0 (D )
Project Costs and MSI Capital Funding Applied
Reporting Year Expenditures and Funding Sources

(D (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
R em aining
Rem aining M SI T otal Actual N on-Q ua lifying Portion of Portion o f Reporting Y e a r M SI Funding Qualifying
Project Qualifying Reporting Y e a r C osts Included Reporting Y e a r Reporting Y e a r Qualifying A p p lie d to Project C osts to
Application - Project N am e Status Project C osts Project C osts in Reporting Qualifying Q ualifying Project C o s ts to P revious (4) and be F un ded from
C A P No. from C olum n 11 Y e a r Project Project C osts to Project C osts to b e F u n ded from to Reporting M SI Allocations
o f Previous C osts be F u n ded from b e Funded M SI Y e a r (9) (4+9-10)
Y e a r’s S F E O th e r G ran t from Municipal [5-(6+7+8)j Qualifying
P rogram s S ources Project C osts
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Total 0 0 (E) 0
Total Funding Available for Future Years (D-E) 0 (F)
MSI0002 (2015/01) Page 1 of 2

Page No.00481
Prepared By
Print N am e Title
Telep h o n e N um ber (include area code) Em ail A d d re ss
Certification
T h is is to certify that all information contained in this Statem ent o f Funding a n d Expenditures is a true a n d correct
representation o f actual funding an d costs, and that this information com plies with the M SI Capital Progra m G u idelines
a n d funding agreem ents fbr this grant program . It certifies that all non-qualifying costs, funding from other grant
program s, and funding from m unicipal sources defined fbr this program h a ve been identified in this statement. It also
certifies that the M SI Capital Funding Applied to Previous and Reporting Y e a r Q ualifying Project C osts represents the
Municipality's designation o f M SI funding to the respective qualifying project costs, irrespective o f the Municipality's
m ethod o f paying for these costs.
In all respects, this Statem ent confirm s com pliance with the term s o f the Municipal Sustainability Initiative
M em orandum o f A greem ent between Alberta Municipal Affairs and the Municipality.
Print N am e D a te o f Signature
Telep h o n e N um be r (include area c ode) Signature o f C h ie f Adm inistrative O fficer
Return Completed Statement of Funding and Expenditures by May 1,2015

G ra n ts and Education P roperty T a x Branch
G ra n t Accountability
17th Floor, 1 0 1 5 5 - 102 Street
Edm onton, Alberta T 5 J 4 L 4
o r b y fax: 780422-913 3
o r b y Em ail: m a.m sicapitalgrants@ gov.ab.ca
If y o u h a ve an y questions, please contact a com pliance ad viso r b y dialing 780-427-2225 o r toll free b y first dialing
310-0000.
Legal Statement
T h e personal information being collected o n this form m il b e used to adm inister the Municipal Sustainability Initiative.
T h e personal information is being collected un der the authority o f section 33(c) o f the Freedom o f Inform ation and
Protection o f Privacy (F O IP ) A ct a n d will b e m anaged in accordance with the p riva cy provisions in the F O IP A ct. If y o u
h a ve a n y q uestions concerning the collection o f this information, plea se contact the Director, G ra n t Accountability,
Alberta Municipal Affairs, 17th Floor, 10155 -1 0 2 Street, E dm onton, Alberta, T 5 J 4L4.
MSI0002 (2015/01)
Row/Column Explanation
R o w A •Total Fun din g C a rry-F o rw a rd from P re vio u s Y e a r Th e remaining balance from the Municipal Certification
Sum m ary Report attached to the 2013 S F E certification letter, or amount reported in Row F of the 2013 S F E .
R o w B •F u n d in g A llo cation In R eporting Y e a r Full MSI Capital Project funding allocation in 2014, whether o r not
paym ent(s) has been received. T h e municipality's full funding allocation is listed on the ministry website at
www.m unlclpalaffalre.alberta.ca/M SI.cfm .
R o w C - C red it Item s (In clu d in g Incom e Earned ) In R eporting Y e a r A n y credit Hems that result In net proceeds to the
municipality in the reporting year, such as income earned on deposits and Investments, and rent and other Income derived
from capital assets. See section 6.2 and 6.3 of the 2014 Capital Program Guidelines.
R o w D •Tota l Fun din g A vailab le In R eporting Y e a r A calculated total of Rows A, B, and C.
R o w E - T otal: A calculated total o f line items in Column 10. R o w E (b e lo w C olum n 10) ca n n ot exceed R o w D.
R o w F - Total Fun din g A vailab le fo r Future Y e a rs: Total funding to be carried forward to 2015. A calculated total of R ow D
minus Row E. R o w F m u st be $0 o r greater.
C o lu m n 1 - Project A p p lic atio n •C A P N o .: T h e C A P No. included in the Minister's Project Acceptance letter.
C o lu m n 2 • Project Nam e: A s stated In the Minister's Project Acceptance letter.
C o lu m n 3 •S tatus: Report on all approved projects, regardless of status:
LEG EN D
In Progress - project has started with o r without expenditures in reporting year;
Not Started - project has not yet begun;
d e la ye d - project w as started but has since been delayed with no expenditures in reporting year,
Completed/Onaolno Funding - project was completed in reporting year or a previous year, and has remaining
qualifying costs that will be funded from future years' MSI funding;
Completed/Fully Funded - project has been completed in reporting year and no additional MSI funds will be applied.
Once a project has been reported as Completed/Fully Funded, it is not reported on in future years; and
Withdrawn - project is not proceeding and no M SI funding has been applied to date.
C o lu m n 4 •R em aining Q ua lifyin g P roje ct C o s ts from P re v io u s Y e a rs to b e F u n d e d from M SI: Am ount for each project
from Column 9 of the Municipal Certification Sum m ary Report attached to the 2013 S F E certification letter, o r amount
reported in Colum n 11 of the 2013 S F E .
C o lu m n 5 - T ota l A c tu al R e p o rtin g Y e a r P roject C o s ts : T h e total expended o n the project in 2014 including ineligible
costs, costs that w ere funded b y other grant programs, and costs that w ere funded from municipal sources including
borrowings (excluding costs that w ere funded b y other municipalities).
C o lu m n 6 - N o n -Q u a lifyin g C o s ts Includ ed in R eporting Y e a r P roje ct C o s ts : T h e portion o f project costs from Colum n 5
that w ere ineligible for MSI funding (see Schedule 1 o f the 2014 Capital Program Guidelines).
C o lu m n 7 - Po rtio n o f R eportin g Y e a r Q u a lifyin g P roject C o s ts to b e F un d ed from O th e r G ra n t Prog ra m s: T h e portion
of project costs from Colum n 5 that were, o r will be, funded from federal o r other provincial grant programs.
C o lu m n 8 - P o rtio n o f R eporting Y e a r Q u a lifyin g P roject C o s ts to b e F u n d e d from M unicipal S o u rc e s: T h e portion of
project costs from Colum n 5 that will be funded from municipal sources including reserves, accumulated surpluses, o r
municipal revenues, and includes project costs that have been financed through borrowings that win be repaid from municipal
sources.
C o lu m n 9 •R eporting Y e a r Q u a lifyin g P roje ct C o s ts to be F un d ed from M SI: T h e net amount of project costs expended
in 2014 that qualify for MSI funding. T he se costs m ay exceed the amount of MSI funding available in the reporting yea r
where the municipality intends to hind the excess in a future program year. A calculated total for each proj8ct from Colum n 5
minus the sum of Colum ns 6-8.
C o lu m n 10 - MSI F un d in g A p p lie d to P re vio u s an d to R eporting Y e a r Q u a lifyin g P roject C o s ts : T h e am ount o f MSI
funding applied to qualifying project costs.
C o lu m n 11 - R em aining Q u a lifyin g P roject C o s ts to b e F u n d e d from F uture Y e a r MSI A llo ca tion s: T h e calculated total
of Columns 4 plus 9 minus 10 that represents the excess of accumulated qualifying project costs. This excess will be carried
forward to be funded in a future program year.
Page 2 of 2

Page No.00482
Municipal Sustainability Initiative (MSI)
Government 2014 Operating Program
Statement of Funding and Expenditures (SFE)
Municipality Office Use Only

Municipal Code SFE#
■ Due Date - The due date for submitting the 2014 SFE to Alberta Municipal Affairs is May 1 ,2015. ■All MSI operating expenditures listed on this statement must assign a Functional Category that
aligns with the Government-Wide Objectives for Municipal Grant Funding. See page 2 for
row/column explanations.
■ Z015 Allocation - The 2015 Funding Allocation will not be released until the 2015 MSI Operating * Municipalities can carry forward operating funding for one year after the year in which the funding
Program Spending Plan is received, the 2014 SFE is received, the 2013 SFE is certified by Alberta was allocated. The 2014 MSI conditional operating grant allocation must be expended by
Municipal Affairs, and the 2013 allocation has been reported as fully expended. December 31, 2015.
MSID003 (2015/01) Page 1 of 2

Page No.00483
Prepared By
Print N am e Title
Te le p h o n e N um b er (in clud e are a co d e) E m a il A d d re s s
Certification
T h is is to certify that all information co ntained in this Statem en t of F u n d in g a n d Exp e n d itu re s is a true an d correct
representation of a ctual funding, expenditures and total carry-forw ard, T h is information co m p lie s with the M SI
O perating Pro gram G u id e lin e s and funding ag ree m en ts for this gran t program .
In all re sp e cts, this Statem ent confirm s co m p lian ce with the term s of the M unicipal Su stain ab ility Initiative
M em orandum of A gree m e n t between A lb e d a M unicipal A ffairs and the M unicipality.
Print N am e D ate of S ig n a tu re
T e le p h o n e N um b er (in clud e are a co d e) S ig n a tu re o f C h ie f A dm inistrative O fficer
Return Completed Statement of Funding and Expenditures by May 1, 2015
A lberta M unicipal A ffairs

G ran ts and E d u ca tion Property T a x B ran ch
G rant A ccountability
17th Floor, 1 0 1 5 5 - 1 0 2 Street
Edm onton, A lberta T 5 J ALA
o r by fax: 7 8 0 -4 2 2 -9 1 3 3
or by Em ail: m a .m sio p e ra tin g g ran ts@ go v .ab .ca
If you h ave an y q u estio ns, p le a s e contact a co m p lian ce a d v iso r by dialing 7 8 0 -4 2 7 -2 2 2 5 or toll free by first dialing
3 1 0 -0 0 0 0 .
MSI0003 (2015/01)
Row/Column Explanation
R o w A - T o ta l F u n d in g C a r r y -F o r w a r d fro m P r e v io u s Y e a r : A m ou n t provided on 2 0 1 3 S F E certification letter, or

am ount reported in R o w F of the 2 0 1 3 S F E .
R o w B - F u n d in g A llo c a t io n in R e p o r t in g Y e a r : Fu ll M SI O p era ting funding allocation in 2 0 14, w hether o r not a
p ay m e n t(s) h a s b ee n received . T h e m unicipality's full funding allocation is listed on the m inistry w eb site at
w w w .m unicipalaffairs.alberta.ca/m si.cfm .
R o w C - C r e d it Ite m s (in c lu d in g In c o m e E a r n e d ) in R e p o r t in g Y e a r : Cred it item s that result in net p ro ce e d s to the
m unicipality in the reporting y ear, s u ch a s in co m e ea rn ed on d ep o sits an d investm ents, and d o nation s o r contributions
in-kind. S e e sectio n 6.2 and 6 .3 of the 2 0 1 4 O p erating P ro g ra m G u id e lin e s.
R o w D - T o ta l F u n d in g A v a ila b le in R e p o r t in g Y e a r : A ca lcu la te d total of R o w s A , B. an d C .
R o w E - A c c e p t e d S p e n d in g P la n A m o u n t: A ca lcu lated total of line item s in C o lu m n 2.
R o w F - T o ta l R e p o r t in g Y e a r E x p e n d it u r e s : A ca lcu lated total o f line item s in C o lum n 3. R o w F c a n n o t e x c e e d D.
R o w G - T o ta l R e p o r t in g Y e a r F u n d in g R e m a in in g : To tal funding to be carried forward into 2015. A ca lcu la te d total
of R o w D m inu s R o w F. R o w G m u s t b e $0 o r g re a te r.
C o lu m n 1 - F u n c t io n a l C a t e g o r y : Fro m the dropdow n list provided, se le ct the Fun ction al C a te g o ry that M SI
operating funding h a s b een estim ated on y o u r 2 0 1 4 sp e n d in g plan and exp e n d e d on in the reporting year. S e e
S c h e d u le 2 of the 2 0 1 4 O p era ting P ro g ra m G u id e lin e s for the Fun ction al C a te g o ry definitions an d the G o ve rn m e n t-
W id e O b je ctiv e s that they align with.
C o lu m n 2 - E s tim a te d E x p e n d it u r e s on th e 2 0 1 4 S p e n d in g P la n : T h e am ount of M SI operating funding allocated
to a Fun ction al C a te g o ry on the la st a cce p te d 2 0 1 4 O p erating P ro g ra m S p e n d in g P lan . T h e total is in the M inister's
a cce p te d am ount.
C o lu m n 3 - A c t u a l A m o u n t E x p e n d e d in R e p o r t in g Y e a r : T h e am ount of M SI operating funding exp e n d e d on
eligible operating exp e n d itu re s by Fun ction al C a te g o ry in the reporting year.
Legal Statement
T h e p erso n al information bein g collected on this form will be u se d to ad m inister the M unicipal Su stain ab ility Initiative
T h e p erso n al information is b ein g collected under the authority of section 3 3 (c) of the Freedom of Information and
Protection of Privacy (FOIP) Act and will b e m a n a ge d in a c c o rd a n c e with Ihe privacy p ro visio n s in the FOIP Act. If you
h a v e an y q u e stio n s co n ce rn in g the collection of this inform ation, p le a s e contact the Director, G ran t Accountability,
A lberta M unicipal Affairs, 17th Floor, 10155 - 102 Street, Ed m o n to n, A lberta, T 5 J 4 L 4 .
Page 2 of 2

Page No.00484
Lesser Slave Lake Regional Wildfire Recovery Plan (LSLRWRP)
2014 Statement of Funding and Expenditures (SFE)
M u n icip a lity O ffic e U s e O n ly

M u n ic ip a l C o d e P ro g ra m Y e a r
2014
■ The due date for submitting the 2014 SFE to Municipal Affairs is • The SFE forms, wholy or in part, the reporting requirements as
May 1,2015. outlined in the terms and conditions of each project grant
■ All projects listed on this statement must first be accepted on
previously submitted and approved project applications.
Project Amounts and Funding Applied
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
File No, Project Name Project Start Project Status Grant Amount Credit Items Transfers Grant Amount Grant Amount Grant Amount
(Office Use Only) Date Completion Remaining at Start Amount To Available Expended in Remaining at End of
Date of Reporting Year in Reporting Reporting Year Reporting Year
Year
'The municipality is also to provide a copy of the Council's resolution to cancel municipal and education property taxes, local
improvement taxes, and seniors foundation taxes for destroyed residential and non-residential (excluding linear) properties. The
resolution must include the roil number, legal description, and amount of taxes owed for each property.
Total
G ra n t / In te re s t S u m m a ry
Total F unding Available at Start o f Reporting Year 0 (A)
Incom e Earned in R eporting Year 0 (B)
Total F unding Available in R eporting Year 0 (C)
Total Expenditures in Reporting Year 0 (D)
Total Funding Rem aining at End o f R eporting Year 0 (E)

Page No.00485
P re p a re d B y
Print Name Title
Telephone No. (incl. area code) Email
C e rtific a tio n
This is to certify that all information contained in this Statement of Funding and
Expenditures is a true and correct representation of actual funding, expenditures and
total carry-forward.This information complies with the Administrative Guidelines and
funding agreements for grant funding provided under the Lesser Slave Lake Regional
Wildfire Recovery Plan.
In all respects, this Statement confirms compliance with the terms of the Municipal
Affairs Grants Regulation, the Lesser Slave Lake Regional Wildfire Recovery Plan
Memorandum of Agreement between Alberta Municipal Affairs and the Municipality, as
well as the terms and conditions set out in project specific grant approval forms.
Signature of Chief Administrative Officer Print Name
Date of Signature Telephone No. (incl. area code)
R e tu rn C o m p le te d A n n u a l P ro je c t S u m m a r y b y M ay 1, 2015
Grants and Education Property Tax Branch
17th Floor, 10155- 102 Street
or by fax: 780-422-9133
or by email: rcp.grants@gov.ab.ca
If you have any questions, please contact Glenys Holmberg by dialing 780-427-2225
or toll free by first dialing 310-0000,__________________________________________
Row / Column Explanation
C o lu m n 1 - F ile No. (O ffic e U s e O n ly ): Please leave blank.

C o lu m n 2 - P r o je c t N am e: Provided on the grant approval form or in the Minister's acceptance letter.
C o lu m n 3 - P r o je c t S ta rt D ate: Provided on the grant approval form (as indicated on the project application form).
C o lu m n 4 - P r o je c t C o m p le tio n D a te : Provided on the grant approval form (as indicated on the project application form).
C o lu m n 5 - S ta t u s : There are two options; Complete and In Progress (work is ongoing), Once a project has been
reported as Complete, it is not reported on in future years.
C o lu m n 6 - A p p ro v e d G ra n t A m o u n t: Provided on the grant approval form in the Minister's acceptance letter.
C o lu m n 7 - C re d it Ite m s: Any income earned on the total grant amount in the reporting year, such as income earned on
deposits or investments, as well as funds transfered from other approved projects. Income earned becomes part of the total
funding available. See the LSLRWRP Admininstrative Guidelines.
C o lu m n 8 - T r a n s fe r s : Reallocation of grant funds, including income earned, between approved projects. (Each transfer
requires a separate, approved grant amendment form as per the LSLRWRP Administrative Guidelines.)
C o lu m n 9 - G ra n t A m o u n t A v a ila b le in R e p o rtin g Y e a r: Equals the grant amount remaining for each individual project at
the end of the previous reporting year.
C o lu m n 10 - G ra n t A m o u n t E x p e n d e d in R e p o rtin g Y e a r: The amount of funding applied to eligible project costs in the
reporting year.
C o lu m n 11 - G ra n t A m o u n t R e m a in in g at E n d o f R e p o rtin g Y e a r: The amount of approved funding for each individual
project still available at the end of the reporting year. This calculated result is the Grant Amount Available in Reporting Year
(Column 7) less the Grant Amount Expended in Reporting Year (Column 8).
R o w A - T o ta l F u n d in g A v a ila b le at B e g in n in g o f R e p o rtin g Y e a r: The sum of all approved grant amounts received in

2013 and amount available at end of previous year.
R o w B - In c o m e E a rn e d in R e p o rtin g Y e a r: Amount of income earned on the total grant amount available in the reporting
year. Income earned annually becomes part of the total funding available.
R o w C - T o ta l F u n d in g A v a ila b le in R e p o rtin g Y e a r: Funding available to be applied in 2013. A calculated total of Row
A and Row B.
R o w D - T o ta l E x p e n d itu r e s in R e p o rtin g Y e a r: The total of all reported funding applied in 2013. This number should
equal the total of Column 8. R o w D c a n n o t e x c e e d R o w C .
R o w E - T o ta l F u n d in g R e m a in in g at E n d o f R e p o rtin g Y e a r: Total funding to be carried forward to 2014. A calculated
total of Row C minus Row D. R o w E m u s t b e SO o r gre a te r.

Page No.00486
Lesser Slave Lake Regional Wildfire Recovery Plan
Grant Approval Form - Amendment
Name of Grant Project NAM E
In addition to the conditions set out in the Lesser Slave Lake Regional W ildfire Recovery Plan
(LSLRW RP) M em orandum of Agreement, the LSLRW RP Grant Approval Form (hereinafter
called the “Original Grant Approval Form ”) is amended by deleting and replacing the following
term s and conditions:
Amount of Grant $...
Revised
Purpose of Grant To fund...

Revised
Qualifying Use of The grant funding will be used by the m unicipality to ...
Funding
Revised
Time Period of Project The m unicipality may not use any part o f the Grant, including any
income earned thereon, to pay for work done or m aterials obtained
Revised
before the project start date of...
The project will be com pleted by...
Eligible Amount of The funding provided for this project is lim ited to ..., less any
Project am ounts received for this project through other grant program s
and/or other recoveries.
Revised
I approve the am endm ent for this project, subject to the term s and conditions set out in the
LSLRW RP M em orandum of A greem ent and subject to the terms and conditions set out in the
Original G rant Approval Form dated <Date> and amended on <Date.
THIS SPACE INTENTIONALLY LEFT BLANK
Page 1 o f 2

Page No.00487
Lesser Slave Lake Regional Wildfire Recovery Plan
Grant Approval Form - Amendment
Her Majesty the Queen

in Right of the Province of
Alberta as Represented by
the Minister of Municipal Affairs
Per:___________________________
Witness (or Seal) Assistant Deputy Minister
Date:
The terms and conditions for this project as set out in the LSLRW RP M em orandum of
Agreement, the Original G rant Approval Form, and this G rant Approval Form - Am endm ent
are acceptable to the Town o f Slave Lake/M unicipal D istrict of Lesser Slave River No. 124.
Per:___________________________
Witness (or Seal) Chief Elected Official
Date:
Per:_____________________________________
Witness (or Seal) Duly Authorized Signing Officer
Date:
Page 2 o f 2

Page No.00488
Southern Alberta Flood Response Program {SAFRP)
Government
2 0 1 4 / 1 5 S ta te m e n t of Fu n d in g and E x p e n d itu re s (SFE)
M u n icip a lity Nam e:

P ro ject Start D ate: P ro je ct C o m p le tio n D ate:
Project Costs and Funding Sources

(A) (B> (C) (D) (El (F) (G) (H) (■ ) U) |K| (L) (M )
P ro je ct P ro je ct N a m e T o ta l A ctu a l In e lig ib le P r o je c t C o s ts P ro je c t C o s ts P r o je c t C o s ts S A F R P E lig ib le SA FRP C re d it Ite m s T o t a l F u n d in g S A F R P G ra n t V a r ia n c e
N um ber P ro je ct P ro je c t F u n d e d fro m F u n d e d fro m Sh ared b y P ro je c t C o s ts A p proved A v a ila b le A p p lie d (M = K -L )
C o sts C o s ts O th e r G ra n t th e D is a s te r M u n ic ip a lit y (H = C - G ra n t A m o u n t [K = l+ J]
P ro g ra m s R e c o v e ry [D + E + F + G ])
P ro g ra m
0 O O
0 O 0
0 0 O
0 0 0
If a positive variance is Identified In Column (M), please contact a grant compliance advisor by dialing 780-427-2225 or toll free by first dialing 310-0000
T h is is to c e rtify th a t all in fo rm a tio n co n ta in e d in this S t a te m e n t o f F u n d in g a n d E x p e n d itu re s is a tru e a n d c o rr e c t re p re s e n ta tio n o f a c tu a l fu n d in g an d c o s ts , and th a t th is in fo rm a tio n c o m p lie s w ith th e SA FR P
M e m o ra n d u m o f A g re e m e n t, th e S A F R P A d m in is tra tiv e G u id e lin e s, an d t h e P ro je c t A p p ro v a l L e tte r!' ;). It c e rtifie s th,at all in e lig ib le co sts, c o s ts fu n d e d fro m o th e r g ra n t p ro g ra m s, c o s ts fu n d e d fro m th e D is a s te r
R e co v e ry P ro g ra m , a n d c o s ts sh a re d by th e m u n icip a lity as d e fin e d fo r th is p ro g ra m h a v e b e e n id e n t ified in th is stats tm en t,
Print N a m e S ig n a tu re o f C h ie f A d m in is tra tiv e O ffic e r
T e le p h o n e N u m b e r (In clu d in g A re a C o d e ) D ate o f S ig n a tu re

Page No.00489
Column Explanations
C o lu m n A - P ro je c t N u m b e r : T h e p ro je ct n u m b e r p ro v id e d in th e M in iste r's p ro je ct a p p ro v a l letter.
C o lu m n B - P ro je c t N a m e : T h e p ro je c t n am e p ro v id e d in th e M in iste r's p ro je ct a p p ro v a l le tt e r (as in d ic a te d o n th e
p ro je ct a p p lica tio n form |,
C o lu m n C - T o t a l A c tu a l P ro je c t C o s ts: T h e to ta l e x p e n d e d on th e p ro je ct in clu d in g in e lig ib le co sts, c o sts fu n d e d by P rin t N a m e T itle
o th e r g ra n t p ro g ra m s, c o sts fu n d e d by the D is a s te r R e co v e ry P ro g ra m , a n d c o s ts th a t w e re fu n d e d fro m m u n ic ip a l
s o u rc e s (e x clu d in g c o s ts th a t w e re fu n d e d by o th e r e n titie s).
C o lu m n D - In e lig ib le P ro je c t C o s ts: T h e p o rtio n o f e lig ib le p ro je c t c o sts fro m C o lu m n C th a t w e re in e lig ib le fo r
S A F R P g ra n t fu n d in g .
C o lu m n E - P ro je ct C o s ts F u n d e d fro m O th e r G ra n t P ro g ra m s : T h e p o rtio n of e lig ib le p ro je c t c o sts fro m C o lu m n C
th a t w e re fu n d e d fro m fe d e ra l o r o th e r p ro v in cia l g ra n t p ro g ra m s.
C o lu m n F - P ro je c t C o s ts F u n d e d fro m D is a s te r R e c o v e ry P r o g r a m : T h e p o rtio n o f e lig ib le p ro je ct c o s ts fro m T e le p h o n e N u m b e r (In clu d in g A re a C o d e ) Em ail A d d r e s s
C o lu m n C th at w e re fu n d e d fro m th e D is a s te r R e c o v e ry P ro g ra m .
C o lu m n G - P ro je c t C o s ts S h a re d b y M u n ic ip a lity : T h e p o rtio n o f e lig ib le p ro je ct c o s ts fro m C o lu m n C th a t w e re
fu n d e d fro m m u n ic ip a l s o u rc e s in clu d in g re se rv e s, a c c u m u la te d su rp lu se s, o r m u n icip a l re v e n u e s, an d in clu d e s Return Completed Statement of Funding and Expenditures to:
p ro je ct c o s ts th a t h a v e b ee n fin a n ce d th ro u gh b o rro w in g s th a t w ill b e re p a id fro m m u n icip a l s o u rce s.
C o lu m n H - S A F R P N e t E lig ib le P ro je c t C o sts: T h e to tal a m o u n t o f p ro je c t c o sts th a t q u a lify fo r S A FR P g ra n t
A lb e rta M u n ic ip a l A ffa irs
fu n d in g . C o lu m n H is a ca lcu la te d to tal o f C o lu m n C m in u s th e su m o f C o lu m n s D, E, F, and G.
G ra n ts a n d E d u c a tio n P r o p e r t y T a x
C o lu m n I - S A F R P A p p r o v e d G r a n t A m o u n t: A m o u n t a p p ro v e d in th e M in iste r's p ro je ct a p p ro v a l letter.
1 7 th F lo o r , 1 0 1 5 5 - 1 0 2 S t re e t
C o lu m n J - C r e d it Ite m s : A n y in co m e ea rn e d on th e to ta l g ra n t a m o u n t in th e re p o r tin g y e a r su ch as in c o m e e a rn e d
E d m o n to n , AB T5J 4L4
on d e p o s its o r in v e stm e n ts. In c o m e ea rn ed b e c o m e s p a rt o f th e to ta l fu n d in g ava ila b le . S e e th e S A F R P
A d m in in s tra tiv e G u id e lin e s.
C o lu m n K - T o t a l F u n d in g A v a ila b le : T h e to tal fu n d in g a v a ila b le w h ich m a y be a p p lie d to th e p ro je ct. A ca lcu la te d o r b y f a x : 7 8 0 -4 2 2 -9 1 3 3
to ta l of C o lu m n s I and J. o r b y e -m a il: m a .r e c o v e r y g r a n t s @ g o v .a b .c a
C o lu m n L - S A F R P G r a n t A p p lie d : T h e a m o u n t o f t h e to ta l S A F R P g ra n t a v a ila b le a p p lie d to e lig ib le p ro je ct c o sts
re p o rte d in C o lu m n H.
C o lu m n M - V a ria n c e : T h e ca lcu la te d d iffe re n ce o f th e to ta l fu n d in g a v a ila b le in c o lu m n K m in u s th e S A F R P g ra n t If y o u h a v e a n y q u e s t io n s , p le a s e c o n ta c t a c o m p lia n c e a d v is o r b y d ia lin g
a p p lie d in co lu m n L._______________________________________________________________________________________________________ 7 8 0 -4 2 7 -2 2 2 5 o r to ll fre e b y firs t d ia lin g 3 1 0 -0 0 0 0
Le g a l S t a te m e n t
T h e p e rso n a l in fo rm a tio n b e in g co lle cte d on th is fo rm w ill b e u sed to a d m in is te r th e S o u th e rn A ib e rta Flo o d R e sp o n se P ro g ra m . T h e in fo rm a tio n is b e in g co lle cte d u n d e r th e a u th o rity of
se ctio n 3 3 (c) o f th e Freedom of information and Protection of Privacy (FOIP)Act an d w ill b e m a n a g e d in a c c o rd a n c e w ith th e p riv a cy p ro v is io n s in th e FO IP A ct. If y o u h a v e a n y q u e s tio n s
c o n c e rn in g th e co lle ctio n o f th is in fo rm a tio n , p le a se co n ta c t th e D ire cto r, G ra n t A cc o u n ta b ility , A lb e rta M u n icip a l A ffa irs , 17th Flo o r, 1 0 1 5 5 - 1 0 2 stre e t, E d m o n to n , A lb e rta , T 5 J 4 L4 .

Page No.00490
A nnu al Statem ent o f Fu nd ing and E xp e n d itu re s
Grant Program Name: FEDERAL GAS TAX FUND
Municipality: For Calendar Year: 2014
Government
Region:
Project Expenditure List

m m m f4j <5-a) 15-bl f6> (7) m (9)
Project ID Project Identification
Project Number
Municipal File/
December 31
Status as of
Non-Eligible
Items: GST. This
Provincial
Proj. No.
Admin, Program Maximum Actual
Percent
Actual Developer Earned Provincial Provincial
Work Project Street/ Calendar Year contribution Income Net Eligible Share Grant
Code Buildinq / Area Detailed Location Expenditures etc, Applied Proiect Cost Eliqlble Applied
No projects found
Note: All projects listed on this statement m ust first be accepted on a previously submitted Application for Program A ccep tan ce for this calendar year.
GRANT/INTEREST SUMMARY CERTIFICATION

GRANT INTEREST & other INCOME
Amount Gamed Forward from 2013 (1) T h is is to certify that all information contained in this Statement of Funding and Expenditures is a
12 12
true and correct representation of actual funding and expenditures and that this information
ADD: Received / Earned in 2014 <2> iS 12 com plies with the G uidelines, A dm inistrative Procedures, and other relevant docum entation for
ADD: Transferred from other programs (31 12 12 this grant program . It also certifies that all non-shareable c o s ts defined for this program have been
deducted from the total co st or otherwise excluded from the am ounts identified as Net Eligib le
T O T A L AMOUNT A V AILA BLE (4 >=(1*2,3| JO 12 Project Cost,
L E S S Expenditures (Grant Applied) (5> 12 12
In all respects, the information in this Statement com plies with the terms of the current Program
Net Amount Gamed Forward to 2015 (6>=(4-5) 12 1 2 Agreem ent between Alberta Infrastructure and Transportation and the Municipality.
2009
Dated Name
Integrated Community Sustainability Plan Completed Year_
Signature
Chief Adminisirativs Officer or other authorized
Municipal Administrator I Commissioner/
Manager / Engineer
____________________ Generated: 16-Dec-2015
- End of D ocum ent-
The data displayed on this pan: out a provided tor informational and planning p u rp o rts only. A T ic not responsible for the misuse o r misrepresentation o f the data. Produced from the TlfAS • MGMA application t$-Dec-20i5. Alberta Transportation Copynghi20l5
Page 1

Page No.00491
^ d b e r t f c j
Government
S o u th e rn A lb e rta Flo od R e sp o n se P ro g ra m - O p e ra tin g P ro ject A p p lica tio n
Municipal Affairs
This form should be used for all operating projects, which are defined as those projects that do not involve the
purchase, construction, or rehabilitation of an asset with a useful life greater than one year.
M un icip ality In form ation
Municipality Name:
Address:
Contact Name:
Telephone:
Date: Select a date
P ro je ct Inform ation
1. Project Name
2. Purpose and Use of Grant:

Provide a brief narrative on the
purpose of the proposed
project and details on what the
grant funds will be used for.
3. Budget breakdown by year 2013/14 2014/15 2015/16 + Later TOTAL
A Estimated project Cost
B Other grant contributions
Municipal contributions or other

C
recoveries
Total grant funding requested
D (A-[B+Cj)
4. List names of Other Grants expected:

(from 'B' above)

Page No.00492
5. Project S tart Date: Select a start date
6. Project End Date: Select an end date
7. Indicate in dollars how total project amount will be allocated into the following categories:
Waste and Recycling

Property Tax Relief
Services
Utility Revenue Relief Materials and Goods
Interest Relief Utilities
Contributions to Other
Salaries, Wages, Benefits
Organizations
Contracted Services Volunteer Support
Other Other
Please specify Piease specify
TOTAL
C e r t if ic a t io n
I certify that the information contained in this project application is correct, and that these expenses have not been deemed
eligible on a prior project application, and that the allocated grant amount will be applied in the year and manner described above.
Signature of Chief Administrative Officer Print Name
Date Telephone
Submit signed and completed project applications to:

Municipal Grants Unit
17th Floor, 10155 - 102 Street
or by fax: 780-422-9133
or by email: ma.recovervarants@aov.ab.ca
If you have any questions, please call 780-427-2225 (toll-free by first dialing 310-0000)
The personal information you are providing on this form is being collected to support the administration of the Southern Alberta Flood R e s p o n s e Program and is authorized under section
33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The personal information will be managed in accordance with the privacy provisions of the FOlPAct. It you
have any questions concerning the collection of this information, please contact the Municipal Grants Unit at 780-427-2225 or by writing to the Director, Municipal Grants Unit, 17th Floor,
Page No.00493
Southern Alberta Flood Response Program (SAFRP)
y^dhetfb& Ji Government Town of High River Recovery Funding
. Municipal Affairs
INSTRUCTIONS: This form should be used for all Town of High River Recovery Funding applications under the Southern
Alberta Flood Response Program. This form may not function properly with browsers such as Chrome, Firefox or Opera. If a
browser other than Internet Explorer is being used, please download and save a copy of this form before completing it. For
additional information, please refer to the Town of High River Recovery Funding guidelines. Submit one application per project.
M u n ic ip a lity In fo rm a tio n O ffice U s e O n ly

M u n ic ip a lity N a m e Municipal Code
Town of High River 0148
M a ilin g A d d re s s Project Number
309B Macleod Trail SW, High River, Alberta T1V 1Z5
C o n ta c t N a m e DEPT ID
T e le p h o n e
E m a il D a te
- Select a Date -
G r a n t C o m p o n e n t In fo r m a tio n
Select one funding component for your project. Refer to the High River Recovery Funding guidelines for eligibility details.
□ Critical Infrastructure Support (CIS)

□ Long-Term Recovery Support (LTRS)
□ Revenue Stabilization Support (RSS)
P r o je c t In fo rm a tio n
P r o je c t N a m e :
Project Start Date: - Select a Date - Project Completion Date: _____- Select a Date -
□ Is this application an amendment to a previously approved project? If yes, please indicate the original Project Number.
Project Number:
Reason for Amendment:
Alherta Municipal Affairs Information Request 2015-R-0088—

Page IN®0P494o: 7
iyiunjCjpai Affajrs
C ritic a l In fr a s tr u c tu r e S u p p o r t (C IS )
1. Select which project is being funded under the CIS funding component:
□ Downtown Utilities and Road Repairs (2014/15) □ 2nd Avenue SE Road Reconstruction
□ Montrose Bridge Construction P 9th Avenue SE Road Reconstruction
P McLaughlin Meadows Road Settlement Repairs P 5th SE Road Reconstruction
P Other (please specify below) P 6th Street SW and SW Utilities and Road Repairs
2. Provide a detailed description of the project, including project activities, scope, expecled tangible results and, where applicable, identify
all contributing parties. Applicants may attach additional information as required to add clarity to the project description.
3. Provide project financial information below by year of budgeted expenditure:

Breakdown by Fiscal Year 2014 -2015 2015-2016 2016 -2017 TOTAL
A F u n c tio n a l P la n n in g
B D e s ig n / E n g in e e rin g
C R ig h t- o f-W a y
D C o n s tr u c tio n
E R e h a b ilita tio n
F P u rc h a s e
G O th e r
H S u b to t a l; E s t im a t e d P r o je c t C o s ts
I L E S S : In s u ra n c e R e c o v e rie s *
J D is a s te r R e c o v e ry P r o g r a m (D R P ) A s s is ta n c e *
K O th e r G ra n t C o n tr ib u tio n s * *
L M u n ic ip a l C o n tr ib u tio n s /O th e r R e c o v e rie s
M S u b to t a l: R e c o v e r ie s a n d O t h e r F u n d in g
N T O T A L G r a n t F u n d in g R e q u e s t e d
* Include both actual and anticipated amounts

** List other sources of grant funding for this project {from Line K):
Alberta Municipal 'Affairs Information Request 2015-R-0088

Page N®.g04@50f 7
y4 ih & rb f> Ji Government Town of High River Recovery Funding
Municipal Affairs
Long-Term R eco ve ry S upport (L TR S )
1. Provide a detailed description of the project, including project activities, scope, expected tangible results and, where applicable, identify
all contributing parties. Applicants may attach additional information as required to add clarity to the project description.
2. Select one of the pillars of recovery that this project is aligned with:
□ People □ Economy Q Environment □ Reconstruction
3. Select the outcomes that might be realized through this project:
4. Describe how this project aligns with the Long-Term Recovery Plan:
5. If this is a capital project, is a non-profit organization involved in the management and/or operation of the project?
□ No □Yes If 'Yes', complete the attached Supplementary Certification Form.
6. If this project involves a capital asset, identify the resulting capital asset:
—■ Municipal Affairs
Long-Term R eco ve ry S upport {L TR S )

7. Provide project financial information below by year of budgeted expenditure:
CAPITAL Expenses 2014-2015 2015-2016 2016 -2017 TOTAL
A Functional Planning
B Design / Engineering
C Right-of-Way
D Construction
E Rehabilitation
F Purchase
G Other
H S u b to t a l: E s t im a t e d C a p ita l P r o je c t Costs
1 LESS: Insurance Recoveries*
J Disaster Recovery Program (DRP) Assistance*
K Other Grant Contributions*’
L Municipal Contributions/Other Recoveries
M S u b t o t a l: R e c o v e r ie s a n d O t h e r F u n d in g
N T O T A L G r a n t F u n d in g R e q u e s t e d - C a p ita l
OPERATING Expenses (List all expenses) 2014-2015 2015 -2016 2016 -2017 TOTAL
0 1.
p 2.
Q 3.
R 4.
S 5.
T 6.
U 7.
V S u b to t a l: E s t im a t e d O p e r a tin g P r o je c t C o s ts
w LESS: insurance Recoveries*
X Disaster Recovery Program (DRP) Assistance*
Y Other Grant Contributions”
z Municipal Contributions/Other Recoveries
AA S u b to t a l: R e c o v e r ie s a n d O th e r F u n d in g
BB T O T A L G r a n t F u n d in g R e q u e s t e d - O p e r a tin g
CAPITAL and OPERATING Expenses 2014-2015 2015-2016 2016-2017 TOTAL

GRAND TOTAL
* nclude both actual and anticipated amounts
List other sources of grant funding for this project (from Line K and Line Y):
Alberta Municipal Affairs Information Reque'st '2015-R-0088

Page tNOE004§7|f 7
Government Town of High River Recovery Funding
” Municipal Affairs
Long-Term Recovery Support (LTRS)

Southern Alberta Flood Response Program
Supplementary Certification Form for
Capital Projects Involving Non-Profit Organizations
PROJECT INFORMATION
Municipality: ________
Project Name:
Non-Profit Organization:
NATURE OF PROJECT RELATIONSHIP
□ The municipality is contributing to a project that will be carried out by the non-profit organization, and the project is
located on property owned by the non-profit organization.
n The municipality is carrying out the project and incurring the project costs directly, and the project is located on
property owned by the non-profit organization.
□
RESPONSIBILITY FOR PROJECT RECORDS
□ The non-profit organization has primary responsibility for maintaining the books of accounts and documents related to
the project expenditures.
□ The municipality has primary responsibility for maintaining the books of accounts and documents related to the
project expenditures.
OTHER RESPONSIBILITIES
With regard to this capital project submitted for acceptance under the Long Term Recovery Support (LTRS) component
that involves the non-profit organization identified above, the municipality will:
• maintain adequate control over ongoing public access to the project asset/facility, and over the service that it
provides;
• adequately protect itself against potential losses or dispositions of the project asset/facility; and
• where the project is carried out by the non-profit organization, bind the non-profit organization to all SAFRP
conditions and obligations that apply to the municipality with respect to this project.
The personal information provided on this form or on any attachments is required for the purpose of determining your eligibility for the Southern Alberta Flood R e s p o n s e
Program (SAFRP) and the administration of the program. Your personal information is collected under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy (FOIP) Act and will be managed in accordance with the privacy provisions under the FOIP Act. If your grant application is approved, your name, the
grant program and the amount of the grant may be published on the Government of Alberta Grant Disclosure Portal a s authorized under section 40(1)(b) and (f) of the FOIP
Act. Should you have any questions about the collection, use or disclosure of your personal information, please contact the Grant Program Delivery Unit at (780) 427-2225
or by writing to the Director, Grant Program Delivery, 17th Floor, Commerce Place, 10155 - 102nd Street, Edmonton, Alberta, T5J 4L4.
' ' Alberta Municipal Affairs Information Request 2015-R-0088
Page Noi00498of 7
Municipal Affairs
Revenue Stabilization Support (RSS)
1. Purpose of Grant:
Revenue stabilization funding is available for the 2014 tax year to help address a significant revenue
shortfall caused by a decrease in the town's assessment base due to the 2013 floods. This funding will
ensure the town has access to the financial resources required to deliver municipal services and
continue the recovery process.
2. Please indicate the amount of funding the Town of High River is applying
for under the Revenue Stabilization Support component: $
Note: The municipality may use funding provided under this component for any municipal purpose.
3. Revenue stabilization funding is conditional on the town developing a long-term financial sustainability
plan. Support from Municipal Affairs' Financial Advisory Services is available to help the town develop
this plan. Contact the Manager, Financial Advisory at (780) 427-2225. The plan may be submitted with
the Statement of Funding and Expenditures (SFE).
Alberta Municipal Affairs Information Request 2015-R-0088 _

Page N i.90499 of /
' ... ... ” ~ ' Municipal Affairs
Application Certification and Consent for Release of Information
As CAO of the Town of High River, I authorize the Grants and Education Property Tax (GEPT) Branch to disclose any information
collected for the purpose of administering this funding application to staff in other Government of Alberta departments involved
with the 2013 Alberta Flood recovery. I understand that this information may be disclosed by GEPT for the purpose of
administering this application for funding under the Southern Alberta Flood Response Program; however any disclosure of
persona] information will be done in accordance with the privacy provisions in the Freedom of Information and Protection of
Privacy (FOIP) Act.
I also certify that the information contained in this application is correct, that all program funds will be used in accordance with the
Town of High River Recovery Funding guidelines and that the grant will be applied in the year(s) and manner described above
should this application be accepted by the Minister.
S ignature
D ate
C h ie f A d m in istra tive O ffic e r o r D u ly A u th o riz e d S igning O ffice r Telephone N u m b e r

(P rin t N am e)
Legal Statement
The personal information provided on this form or on any attachments is required for the purpose of determining your eligibility for
the Southern Alberta Flood Response Program (SAFRP) and the administration of the program. Your personal information is
collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act and will be
managed in accordance with the privacy provisions under the FOIP Act. If your grant application is approved, your name, the
grant program and the amount of the grant may be published on the Government of Alberta Grant Disclosure Portal as authorized
under section 40(1 )(b) and (f) of the FOIP Act. Should you have any questions about the collection, use or disclosure of your
personal information, you may contact the Director of the Grant Program Delivery Unit at the address below.
Submission
• Submit one application per project.

• Submit the grant application via mail, fax or email. Applicants are encouraged to save a copy of the
completed form for their own records.
• Use only one method of submission.
• Complete all SAFRP component application details before submitting the form.
• To facilitate the processing of applications, please include in the submission any supporting documents
related to the application.
Submit project applications to:

Grant Program Delivery Unit Telephone: toll free by dialing 310-0000 then, (780) 427-2225
17th Floor, 10155 - 102 Street Fax: (780)422-9133
Edmonton, Alberta T5J 4L4 Email: ma.recoverygrants@gov.ab.ca
d Print Form O Save Form □ Reset Fields

Alberta Municipal Affairs Information Request 2015-R-0088 _
Page No<0050CDr /
Federal Small Communities Fund (SCF)
Project Signage Form
C om m unity
Contact Name
Telephone
Municipalities are required to recognize the SCF through installation of federal signs. Signs must follow
federal signage specifications and should only be installed on sites visible to the public. Installation
should take place 30 days before the start of construction and signs should remain on site for at least
30 days after the project has been completed.
Questions regarding signage requirements can be emailed to ma.scfqrants@gov.ab.ca.
Project Signage
The following project(s) has/have been approved under the SCF and therefore require federal project
signage:
Project Title
Project File Num ber
Does project meet the signage criteria? Y E S □ NO □
If NO, please explain why:
If project m eets the signage criteria, has the Y E S □ NO □

project started?
I f YES:
W hen w as the project start date?
If NO:
W hen is the anticipated start date?
W hen is the anticipated com pletion date?
Has a sign been installed? YES n NO □

N O T E : I f a s ig n h a s b e e n in s talle d , p le a s e
a tta c h a p h o to w h e n re tu rn in g th is form .
Please return this form by O ctober 15, 2015 to:

17,h Floor, 10155- 102 Street
Fax: 780-422-9133
Email: ma.scfqrants@gov.ab.ca.
Alberta Municipal Affairs In -0088

O.00501
Government
I , _______________ , C A O confirm that Council f o r __________________ , has granted Municipal
Affairs, Grants and Education Property T a x Branch (G E P T) permission to use photographs submitted in
connection with the Small Communities Fund grant program. Council has agreed that G E P T may use
the photographs for any purpose including, but not limited to, illustrations, bulletins, publications,
advertisements, and any promotional or educational materials in any medium, now known or later
developed, including posting the photographs on the Internet. Council acknowledges and agrees that
the municipality will not receive any compensation for the use of such photographs.
Signature o f C hief Administrative O fficer Print Nam e
Date Telephone Num ber (include area code)
The p e rso n a l inform ation yo u are providing on this form , o r a n y attachm ents, is being colle cte d to su pport the adm inistration o f
the S m all C om m unities Fund a n d is authorized under section 33(c) o f the Freedom o f Inform ation a n d P rotection o f P rivacy
(FO IP) A c t The p e rso n a l inform ation w ill be m anaged in accordance w ith the p riva c y provisions o f the FO IP A c t I f you have
a n y questions concerning the collection o f this inform ation, please co n ta ct the M unicipal G rants U nit a t 780-427-2225 o r b y
w riting to the D irector, G rant Program D elivery, 17th Floor, C om m erce P lace, 10155 -1 0 2 Street, Edm onton, A lberta, T5J 4L4.
Alberta Municipal Affairs Infi t2B l5-R |p088

~ Page No.00502
Government
Municipal Sustainability Initiative
Government 2014 Capital Project Application
Municipal Affairs
Municipality Information Office Use Only

Municipal Code
Municipality Name
Address Project Application No.
Contact Name
Telephone
Municipal Use Only
Municipal Project Number
Date
• Refer to the 2014 Municipal Sustainability Initiative Capital Program Guidelines for project requirements.
• A separate application is required for each project. Refer to section 4.1 of the guidelines.
Project Information
1. Is this application an amendment to a previously accepted project? Q Yes Q No

If yes, include the original project n u m b e r (i.e. CAP-2560) and the reason fo r the am endm ent in the p ro je ct description below.
2. Project Name:
Anticipated Project Start Date (month/year):
3. Provide a detailed description of the project, including project activities and, where applicable identify all contributing parties.
R efer to section 5.1 o f the guidelines and attach a separate sheet if necessary.
M SI0001 (2014/04) Page 1 of 4

Page No.00503
4. Identify the project category. 5. Identify the resulting capital asset.
% of Total Type of
Functional Category of Project New Rehab Replace Quantity Unit
Project Costs Asset
-Select Road/Street Lane Km.

□ □ □
-Select Bridge Lane Km.
□ □ □
-Select Sidewalk/
□ □ □ Metres
Walkway
-Select
Vehicle □ □ □ Units
Functional Cateaories: Total Maintenance
Units
- Roadways and Bridges Equipment □ □ □
- Public Transit Ancillary/
- Water Small □ □ □ Units
- Wastewater Equipment
- Storm Sewer
- Solid Waste Management Rail Line □ □ □ Km.
- Police Water Line Metres
□ □ □
- Fire
- Disaster and Emergency Services Wastewater
□ □ □ Metres
- Ambulance and First Aid Line
- Other Protective Services Storm
- Airports Sewer Metres
□ □ □
- Common and Equipment Pool Conduit
- Infrastructure Management Systems
- General Government and Administration Building □ □ □ Sq. Metres
- Public Health and Welfare Treatment/
- Parks, Recreation and Sports Facilities Cu. Metres
Processing □ □ □
- Libraries Per Day
Facility
- Other Community and Recreation
- Other Other □ □ □
6. Select all outcomes that might be realized by funding this project under the MSI.
i— 1 Management of growth i— 1 Development and/or maintenance of 1—| Greater municipal
1pressures priority municipal infrastructure '—' viability/sustainability
i—i Maintenance of safe, healthy, i—i Enhanced municipal service 1—| Opportunity to collaborate
* vibrant communities •—Jdelivery '—' with neighbours
7. The asset resulting from the project will be owned by:

|~~1 The municipality Q A non-profit organization
□ Another municipality or group of municipalities Q Other: ________________________________
8. Is a non-profit organization involved in the management and/or operation of the project? QYes | |No
I f y e s , c o m p le t e th e S u p p le m e n t a r y C e r tific a tio n F o r m , a v a ila b le o n t h e M S I w e b s it e .
9. Will the project involve the use of municipal forces to carry out the project? EDYes | |No
I f y e s , c o m p le t e th e D e c l a r a t io n s e c tio n o n p a g e 4 o f th is a p p lic a tio n .
MSI0001 (2014/04) Page 2 of 4

Page No.00504
Financial Information
10. Provide project financial information below by year of budgeted expenditure.
2011 2012 2013 2014 2015 2016 2017 2018 2019-21
A Functional Planning
B Design/Engineering
C Right-of-Way
D Construction
E Rehabilitation
F Purchase
Interest on MSI-
Funded Project
G Borrowing (complete
the Declaration
section on page 4)
Other
H
Total Project Costs

l (sum of lines A 0 0 0 0 0 0 0 0 0
through H)
Ineligible Costs
J (refer to Schedule 1
of the guidelines)
Portion of Eligible
Project Costs to be
Funded from Other
K
Grant Programs
(identify grant sources
in question 11)
Portion of Eligible
Project Costs to be
L Funded by Your
Municipality
Portion of Eligible
Project Costs to be
M Funded from MSI 0 0 0 0 0 0 0 0 0
(line I less the sum
o f lines J, K, L)
Amount of MSI
Funding to be
N
Applied by Source
Year
11. Sources of Other Provincial or Federal Grant Program Funding (fo r Line K above J:
I— | Alberta Municipal r— i Canada Alberta Municipal Q Major Community Facilities Program

'— ' Infrastructure Program '— ' Rural Infrastructure Fund
i—I Alberta Municipal Water/ Q Water for Life □ Building Canada Fund
'— ‘ Wastewater Partnership "
I— | Federal Gas Tax Fund {formerly New Q Other

'— ' Deal for Cities and Communities)
J Basic Municipal Transportation Grant (2013 and previous)
MSI0001 (2014/04) Page 3 of 4

Page No.00505
Declaration
Please confirm that:
I I A Multi-Year Capital Plan has been prepared in which this project appears. R e fe r to section 5.3 o f the guidelines.
Where applicable, please confirm that:
] The use of municipal forces will result in a more efficient, timely, and/or cost-effective project.
] ] MSI funds used towards borrowing costs will allow for cost-savings and/or efficiency gains.
P rint Name Telephone N um ber
Date o f Signature Signature o f C h ie f Adm inistrative O fficer
I certify that the information contained in this project application is correct, that all MSI funds will be used in accordance with
the MSI Capital Program Guidelines and the MSI Memorandums of Agreement, that these expenses have not been deemed
eligible on a prior project application, and that the allocated grant amount will be applied in the year and manner described
above once this project application has been accepted by the Minister.
Legal Statement
The personal information being collected on this form will be used to administer the Municipal Sustainability Initiative program,
The personal information is being collected under the authority of section 33(c) of the Freedom o f Inform ation and P rotection
o f P rivacy (FOIP) A c t and will be managed in accordance with the privacy provisions in the FOIP Act. If you have any
questions concerning the collection of this information, please contact the Director of the Grant Program Delivery Unit at the
address below.
Contact Information
Project application forms, guidelines and additional program information are available on the program website at
www.municipalaffairs.alberta.ca/msi-materials-resources.cfm.
Submit project applications to:

Grant Program Delivery Unit
17th Floor, 10155- 102 Street
Telephone: toll-free by dialling 310-0000 then, 780-427-2225

Fax:780-422-9133
Email: ma.msicapitalgrants@gov,ab.ca
Applications may also be submitted through the MSI Online System (MSIO). See section 5.1 of the guidelines for details.
MSI0001 (2014/04) Page 4 of 4

Page No.00506
Municipal Sustainability Initiative
y i i b & r b f r j i Government 2015 Capital Project Application
Municipal Affairs
M u n ic ip a lity In fo rm a tio n Office Use Only

Municipal Code
Municipality Name
Address Project Application No.
Contact Name
Municipal Use Only
Telephone
Municipal Project Number
Date
Refer to the 2015 Municipal Sustainability Initiative Capital Program Guidelines (available on the MSI website) for information to assist
you in completing this application.
Project Information
1. Is this application an amendment to a previously accepted project? □ Yes □ No

I f yes, please include the original p ro je ct num ber (e.g., CAP-2560) and the reason fo r the am endm ent in the pro je ct description
below (i.e., change to p ro je ct scope, costs, funding sources a nd/or timing).
2. Project Name:
Anticipated Project Start Date (month/year):
3. Project description:
Please provide sufficient detail to determ ine project eligibility, including the proposed asset(s), activities, and partne rsh ip s/
contributing parties, where applicable. Attach a separate sheet i f necessary.
MSI 0001 (2015/05) Page 1 of 4

Page No.00507
4. Identify the project category. 5. Identify the resulting capital asset.
% of Total Type of
Functional Category of Project New Rehab Replace Quantity Unit
Project Costs Asset
-Select Road/Street Lane Km.

□ □ □
-Select Bridge Lane Km.
□ □ □
-Select Sidewalk/
□ □ □ Metres
Walkway
-Select
Vehicle □ □ □ Units
Functional Categories: Total Maintenance
Units
- Roadways and Bridges Equipment □ □ □
- Public Transit Ancillary/
- Water Small □ □ □ Units
- Wastewater Equipment
- Storm Water
Rail Line □ □ □ Km.
- Solid Waste Management
- Police Waterline Metres
□ □ □
- Fire
- Disaster and Emergency Services Wastewater
□ □ □ Metres
- Ambulance and First Aid Line
- Other Protective Services
- Airports Storm Water
□ □ □ Metres
- Common and Equipment Pool Conduit
- Infrastructure Management Systems
- General Government and Administration Building □ □ □ Sq. Metres
- Public Health and Welfare Treatment/
- Parks, Recreation and Sports Facilities Cu. Metres
Processing □ □ □
- Libraries Per Day
Facility
- Other Community and Recreation
- Other Other □ □ □
6. Select all outcomes that might be realized by funding this project under the MSI.
|— 1 Management of growth ■—| Development and/or maintenance of i—i Greater municipal
1—1pressures 1—1priority municipal infrastructure * viability/sustainability
i— 1 Maintenance of safe, healthy, |— 1 Enhanced municipal service i—| Opportunity to collaborate
*—1vibrant communities * delivery l—l' with neighbours
7. The asset resulting from the project will be owned by:

□ The municipality □ A non-profit organization
|~1 Another municipality or group of municipalities Q Other:
8. Is a non-profit organization involved in the management and/or operation of the project? Q Yes □ No
If yes, complete the Supplementary Certification Form, available on the M SI website.
9. Will the project involve the use of municipal forces to carry out the project? Q Yes Q No
If yes, complete the Declaration section on page 4 o f this application.
MSI0001 (2015/05) Page 2 of 4

Page No.00508
10. Provide estimated project financial information by year of budgeted expenditure (fill in the blanks below).
2 0 __ 2 0 __ 20 _ 2 0 __ 20 _ 20 _ 20 _ 20__ Total
A Functional Planning 0
B Design/Engineering 0
C Right-Of-Way 0
D Construction 0
E Rehabilitation 0
F Purchase 0
Interest on MSt-
Funded Project
G Borrowing (complete 0
the Declaration
section on page 4)
Other
H 0
Total Project Costs

1 (sum of lines A 0 0 0 0 0 0 0 0 0
through H)
Ineligible Costs
J (refer to Schedule 2 0
of the guidelines)
Portion of Eligible
Project Costs to be
Funded from Other
K 0
Grant Programs
(identify grant sources
in question 11)
Portion of Eligible
Project Costs to be
L 0
Funded by Your
Municipality
Portion o f Eligible
Project Costs to be
M Funded from MSI 0 0 0 0 0 0 0 0 0
(line 1less the sum
of lines J, K, L)
Amount of MSI
Funding to be
N 0
Applied by Source
Year
11. Sources of Other Provincial or Federal Grant Program Funding (fo r Line K above):
i—I Alberta Municipal r—, Canada Alberta Municipal □ Major Community Facilities Program
'— ' Infrastructure Program '— ' Rural Infrastructure Fund
i— | Alberta Municipal Water/ Q Water for Life Q Building Canada Fund

'— ' Wastewater Partnership
I— | Federal Gas Tax Fund (formerly New Q j Other

I— I Deal for Cities and Communities)
3] Basic Municipal Transportation Grant (2013 and previous)
MSI0001 (2015/05) Page 3 of 4

Page No.00509
Declaration
Please confirm that:
~~| A Multi-Year Capital Plan has been prepared in which this project appears
Where applicable, please confirm that:
] ] The use of municipal forces will result in a more efficient, timely, and/or cost-effective project.
] MSI funds used towards borrowing costs (Row G on the financial grid) will allow for cost-savings and/or efficiency gains.
Print Name Telephone N u m be r
Date of Signature Signature of Chief Administrative Officer
i certify that the information contained in this project application is correct, that all MSI funds will be used in accordance with
the MSI Capita! Program Guidelines and the MSI Memorandums of Agreement, that these expenses have not been deemed
eligible on a prior project application, and that the allocated grant amount will be applied in the year and manner described
above once this project application has been accepted by the Minister.
Legal Statement
The personal information provided on this form or on any attachments is required for the purpose of determining your eligibility
for the Municipal Sustainability Initiative (MSI) program and the administration of the program. Your personal information is
collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act and will be
managed in accordance with the privacy provisions under the FOIP Act. if your grant application is approved, your name, the
grant program and the amount of the grant may be published on the Government of Alberta Grant Disclosure Portal as
authorized under section 40(1 )(b) and (f) of the FOIP Act. Should you have any questions about the collection, use or
disclosure of your personal information, you may contact the Director of the Grant Program Delivery Unit at the address below.
Contact Information
Project applications, guidelines and additional program information are available on the MSI website at
www,municipalaffairs.alberta.ca/msi-programresources Refer to the 2015 Capital Program Guidelines for key submission
dates and contacts.
Submit signed and completed applications to:

Attn: Capital Grant Programs
Edmonton AB T5J 4L4
Or by Fax: 780-422-9133
Or by Email: ma.msicapitaiarants@gov.ab.ca
Or through the MSI Online system. Refer to the program guidelines for details.
Questions? Please contact a Grant Advisor at 780-427-2225 (toll-free by first dialing 310-0000).
MSI0D01 (2015/05) P a g e 4 o f4
Page No.00510
Small Communities Fund
Projct Completion Listing
For the period Date to Date
Project Unique Project Approval Completion

Ultimate Recipient Legal Name Identifier Project Title Date (by Canada) Date
iuly 26i$

Page No.00511
CANADA - ALBERTA BCF-SCF SCF File No. 0 23 27 -
Expenditure Cla im Review & A pproval Checklist Claim N o . -
(TO BE USED FOR ALL CLAIMS)
Yes No N/A
Provincial file number on the claim form?
CGA on File
Is the claim for this project?
Is the claim statement dated and signed by an appropriate municipal representative?
Were any costs included in claim incurred prior to project approval date (July 312015)?
Are the costs being claimed within fiscal year eligibility guidelines (i.e. not stale dated)
Are the calculations on Parts A, B and C correct?
Are expenditures in accordance with the Schedule "C" of the SCF Agreement?
Has appropriate proof of payment been provided for each invoice on Part C?
Are all claimed costs directly related to the approved project?
Does claim include any costs for planning or assessment that will be held until final claim to
ensure they account for no more than 15% of total costs?
If an amendment/change to project scope is required as a result of this claim, ensure the
required scope request and rationale is documented and discuss with Director for decision
Confirm "holdbacks" with client?
Have unpaid holdbacks been deleted from the claim?
Will this claim pay out remaining contribution amount prior to submission of the final claim for
costs?
Is this the Final Claim for costs?
Unless the municipality has declared the project economically unfeasible to tender, have any
"in-house" labour costs been claimed, and if so, have they been deemed ineligible?
Have any "in-house" equipment costs been claimed, and if so, have they been deemed
ineligible?
If any costs are disallowed in the checkpoints above, have you contacted the Municipality in
writing/email.
2015 SCF Allocation $

Total Claim Amount $
Provincial Share $
Federal Share $
Final Claim Yes No
Recommended by: Approved by:

G rant A d viso r:_____________________________ D ire c to r:____
Date: Date:

S C F C la im C heck List September 201S Page No.00512
Small Communities Fund (SCF) - PART [A]
Government Municipal Affairs
IN S T R U C T IO N S : T h e in fo rm a tio n p ro v id e d in th is d o c u m e n t w ill c o n s titu te a c o m p le te a p p lic a tio n fo r th e p ro je c t.
A n y s u p p le m e n ta r y d o c u m e n ta tio n w ill n o t b e re v ie w e d a n d w ill n o t im p a c t t h e ra n k in g t h a t re s u lts fro m th e r e v ie w o f
If a browser other than Internet Explorer (e.g. Chrome, Firefox) is being used, please download and
th e a p p lic a tio n m a te ria l.
save a copy of this form before completing it. For additional information, please refer to the Building Canada - Small
Communities Fund guidelines. Submit one application per project by e-mail.
Municipality information
Municipality Name Date of Submission

- Select Date -
Mailing Address
Office Use Only
Contact Person Position Municipal Code
Telephone Number Fax Number Project Number
E-mail Address AR Number
Project Information
Please answer each question. (Click on the icon for additional information regarding each question.)
1. Project Title
2. Project Description - Description must clearly demonstrate project eligibility, see SCF guidelines, (maximum 1,000 characters)
3. Project Location/Address
4. Estimated construction start date: - Select Date - 5. Estimated construction end date: . Select Date -
6. Nature of Project 7. Who will own the resulting infrastructure?
8. Identify the Primary Project Category (mandatory) and Secondary Project Categories (optional) that closely aligns with the project, then assign a
percentage (%) value to each category that make up the total project costs. The totai percentage value of the project costs must equal to 100%.
Refer to SCF Guidelines or dick on the icon for information about categories and examples of projects under each category.
% of Total
PRO JECT C A TE G O R Y
Project Costs
P rim a ry P ro je c t C a te g o r y (re q u ire d )
A %
S e c o n d a r y P r o je c t C a te g o r ie s (if a p p lic a b le )
B %
C %
TOTAL (This must equal to 100%): %
Alberta Municipal Affairs Information Request 201‘5-R-o'bs'S ®

Page No.bb513
P r o je c t In fo r m a tio n
9. Municipalities must support project applications through council resolution. Please identify relevant resolution number and date passed.
Council Resolution Number: Date resolution was passed:
10. Is this a multi-jurisdictional project? Q N o Q Yes I f 'Yes', please complete sections 10(a) and 10(b) below.
10(a). Identify municipal partners including council resolution information.
M u n ic ip a lity /P a r tn e r N a m e C o u n c il R e s o lu tio n N u m b e r D a te R e s o lu tio n W a s P a s s e d

A - Select Date -
B - Select Date -
C - Select Date -
10(b). Identify each partner's financial contribution to the municipal share of project costs. Total percentage value of the total project costs must equal to 100%.
M u n ic ip a lity /P a r tn e r N a m e % o f T o ta l P ro je c t C o s ts
Managing Partner/Applicant % of costs
A % of costs
B % of costs
C % of costs
TOTAL: %
11. Will this project be funded as a public-private partnership (P3)? If 'Yes', please describe, (maximum 1,000 characters) QNo | jYes
E lig ib le C o s ts : + In e lig ib le C o s ts : = T o ta l C o s ts :
Provide estimated cashflow for E lig ib le Costs only (w h o le n u m b e rs O N L Y ):
C o n trib u tio n s 2 0 1 5 -2 0 1 6 2016 -2 0 1 7 2 0 1 7 -2 0 1 8 2018 -2 0 1 9 2019 - 2020 2020+ TOTAL
SCF Contributions
A Federal
B Provincial
S u b -T o ta l:
Municipal Contributions
C Other Federal Grants
D Other Provincial Grants
E Municipal Sources
S u b -T o ta l:
T O T A L : _____________ ____________________________________________________________________________________
Page 2 of 6

Page No.00514
Indicate the sources of Municipal Contributions sections C and D above, if applicable:

O th e r F e d e ra l F u n d s O th e r P ro v in c ia l G ra n ts
□ Gas Tax Fund □ Municipal Sustainability Initiative

□ Alberta Community
Partnership
□ Other (Specify below) □ Green Transit Initiatives Program
□ Other (Specify below)
□ Alberta Water/Wastewater Partnership
□ Water for Life
Expected Outcomes
Please provide a brief response to each question. If the question does not apply to the project, please indicate 'N/A1.(Click on the
icon for additional information regarding each outcome.)
1. Will the project address a significant health and/or safety concern? Ptease describe, (maximum 2,000 characters)
2. Will the project contribute to a cleaner environment? Please describe, (maximum 2,000 characters)
Alberta Municipal Affairs Information Request 20f5-R-008§ °

Page No.00515
^ 4dh e*biK Ji Government Municipal Affairs
Expected Outcomes
Please provide a brief response to each question. If the question does not apply to the project, please indicate 'N/A'.(Click on the
icon for additional information regarding each outcome.)
3. Does the project address an urgent infrastructure need? Please describe, (maximum 2,000 characters)
4. Describe the municipalities' plans to ensure the project will be financially sustainable, (maximum 2,000 characters)
5. Will the project contribute to productivity and economic growth in the community? Please describe, (maximum 2,000 characters)
Page 4 of 6

Page No.00516
Expected Outcomes
6. Please describe other benefits to the local community, (maximum 2,000 characters)
7. Identify project risks and measures to mitigate them, (maximum 2,000 characters)
8. Is the project part of an asset management plan? If 'Yes', please describe, (maximum 1,000 characters) Q ]N o | |Yes
9. Is any part of the project located on federal lands? Q N o Q Yes 10. Will Aboriginal groups be consulted about the project? Q ] No | | Yes
11. Is an environmental assessment required under Federal or Provincial legislation? □ No Q Y e s
i understand that the signature of the Chief Administrative Officer or Duly-

Authorized Signing Officer is required to certify this application.
y S ave Form
* The completed application form (Part A) must be saved and e-mailed to:
STOP ma.scfgrants@gov.ab.ca
* Please print and sign the signature page (Part B) attached to this application, then submit by
fax or by mail. Municipal Affairs must receive this certification on or before April 2, 2015,
^ E-m ail
* Applications without the accompanying completed signature page (Part B) will not be rated.
Alberta Municipal Affairs Information Request 25f53R-SD§8 ®
Page No.00517
Small Communities Fund (SCF) - PART [B]
yQ dhe*b(kji Government Municipal Affairs
P r o je c t In fo r m a tio n
Municipality Name
Office Use Only
Municipal Code
Project Title
Project Number
Date of Submission Contact Person Telephone Number
- Select Date -
A p p l i c a t i o n C e r t i f ic a t i o n
This form must be completed by the Chief Administrative Officer or Duly-Authorized Signing Officer.
Signature Date
Print Name Telephone Number

Chief Administrative Officer or Duly-Authorized Signing Officer
I certify that the information contained in this application is correct, that all program funds will be used in accordance
with the Building Canada - Small Communities Fund guidelines and that the grant will be applied in the year(s) and
manner described above should this application be accepted by the Minister.
L e g a l S ta te m e n t
The personal information provided on this form or on any attachments is required for the purpose of determining your
eligibility for the Building Canada - Small Communities Fund (SCF) Program and the administration of the program. Your
personal information is collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy
(FOIP) Act and will be managed in accordance with the privacy provisions under the FOIP Act. If your grant application is
approved, your name, the grant program and the amount of the grant may be published on the Government of Alberta Grant
Disclosure Portal as authorized under section 40(1 )(b) and (f) of the FOIP Act. Should you have any questions about the
collection, use or disclosure of your personal information, you may contact the Director of Federal Programs Unit at the
address below.
S u b m is s i o n
• Submit one application per project. T h e g ra n t a p p lic a tio n (P a r t A ) m u s t b e s u b m itte d b y e m a il. H o w e v e r,

th e A p p lic a tio n C e rtific a tio n (P a r t B ) m u s t b e s e n t b y fa x o r m a il a fte r it h a s b e e n s ig n e d a n d d a te d .
• Applicants are encouraged to save a copy of the completed form for their own records.
• Complete all application details before submitting the form.
• To facilitate the processing of the application, please ensure the Application Certification (Part B) is mailed or
faxed no later than A p ril 2, 2 0 1 5 .
S u b m it c o m p le te d A p p lic a tio n C e rtific a tio n (P a rt B ) to :

Federal Programs Unit Telephone: toll free by dialing 310-0000 then, (780) 427-2225
17th Floor, 10155 - 102 Street Fax: (780) 422-9133 '
Edmonton, Alberta T5J 4L4 Email: ma,scfgrants@gov.ab.ca
(Si P rint Form SI S ave Form □ R eset Fields

Page 6 of 6

Page No.00518
Canada G overnm ent
Small Communities Fund (SCF)__________________
SCF M UNICIPAL EXPENDITURE CLAIM STATEM ENT - PART A
Project and General Claim Information
M u n ic ip a lit y N a m e :
P r o je c t T itle :
C o n ta c t P e r s o n : T e le p h o n e N u m b e r:
P r o v in c ia l P r o je c t N o ,: C la im N u m b e r :
Is p r o je c t c o m p le te ? C o m p le tio n D a te : Is t h is a F in a l C la im ?
I | Yes Q No □ Yes Q No
P e r io d C o v e r e d B y T h is C la im : F ro m I F irs t Invoice D ate TO I L ast Invoice D ate
Claim Breakdown By Cost Element Including GST

T o t a l C o s ts (in c lu d in g G S T )
In e lig ib le C o s ts (G S T , e tc .)
T o ta l E lig ib le C o s ts (T o ta l C o s ts m in u s In e lig ib le C o s ts )
Certification
This is to certify that all information contained in this Municipal Claim Statement, including parts A, B and C, is
a true and correct representation of eligible costs, and that this information complies with the SCF Program
Guidelines and funding agreement for this grant program. It certifies that all non-qualifying costs, funding from
other grant programs and funding from municipal sources defined for this program have been identified in this
statement.
In all respects, this Statement confirms compliance with the terms of the Small Communities Fund
Memorandum of Agreement between Alberta Municipal Affairs and the Municipality.
Signature Date
Print Name Telephone Number

C h ie f A d m in is tra tiv e O ffic e r o r D u ly -A u th o riz e d S ig n in g O ffic e r
Legal Statement
The personal information provided on this form or on any attachments is required for the purpose of
administering the Building Canada - Small Communities Fund (SCF) Program. Your personal information is
collected under the authority of Section 33(c) of the Freedom of Information and Protection o f Privacy (FOIP)
Act and will be managed in accordance with the privacy provisions under the FOIP Act. Your name, the grant
program and the amount of the grant may be published on the Government of Alberta Grant Disclosure Portal
as authorized under section 40(1 )(b) and (f) of the FOIP Act. Should you have any questions about the
collection, use or disclosure o f your personal information, you may contact the Director o f Federal Programs
Unit at the address below.
Submission
Submit completed Municipal Claim Statement to:
Alberta Municipal Affairs - Grants and Education Property Tax Branch, Federal Grant Programs
Fax: (780) 422-9133 Email: ma.gtfgrants@gov.ab.ca
If you have any questions, please contact the Federal Program Unit by dialing (780) 427-2225 or toll-free by
first dialing 310-0000.
Page No.00519
Project Am endm ent
Government and/or Time Extension Request
Alberta Community Partnership
Legal Statem ent: The personal information being collected on this form will be used to administer the Regional Collaboration Program.
The personal information is being collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy
(FOIP) Act and will be managed in accordance with the privacy provisions in the FOiP Act. If you have any questions concerning the
collection of this information, please contact the Director, Grant Accountability, Alberta Municipal Affairs, 17th Floor, 10155 -102 Street,
Edmonton, Alberta, T5J 4L4.______________________________________________________________________________________________________
Program Year Component: Q Intermunicipal Collaboration Q Municipal Internship
[~~| Viability Review Support Q Strategic Initiatives
□ Mediation and Collaborative Processes Q Metropolitan Funding
Name of Grant Recipient
Name of Project
Grant Amount
The grant recipient hereby requests:
|"~l Project Amendment
From
To
|~ l Time Extension
From Date: (yyyy-mm-dd) To Date: (yyyy-mm-dd)
1. Reason(s) for project change and/or why project not completed on time:
2. Project funds expended to date:
Project Activity G rant Funds Expended to Date
LGS0012 (2015/07) Alberta Municipal Affairs Information Request 20'15-Rl0tf3&

Page No.00520
3. Updated project im plem entation schedule:
Project Activity Expected Completion Date
4. For project amendments, provide specifics on the change in project activities. If applicable, provide a revised budget.
5. Provide any additional information you feel would assist Ministry staff in evaluating your request. For example, a contingency plan to
mitigate further project delays and/or a listing of contract and/or other resources that will be used to complete the project,
Project Amendment and/or Time extension requested by:

Name and Title: Telephone Number Email Address
Date (yyyy-mm-dd) Signature of Chief Administrative Officer or Designate
Digital Signature Instructions
Return completed form to: Municipal Affairs

Grant Accountability
17th Floor 10155-102 Street
Edmonton, AB, T5J 4L4.
Fax: 780-422-9133
Email: acp.grants@gov.ab.ca
LGS0012 (2015/07) Alberta Municipal Affairs Information Request 2015-R-Q088

Page No.00521
^ q ib e tb fc m
MUNICIPAL AFFAIRS
TRANSMITTAL SHEET
Municipal Assessment and Grants - Grants and Education Property Tax
FISCAL YEAR TRANSMITTAL NUMBER BUSINESS UNIT NUMBER OF INVOICES BATCH TOTAL
2015/2016 144A
Goods and /or services received, prices fair and just, and amounts have not previously been paid.
USER COMMENTS
EXPENDITURE OFFICER A P P R O V A L _______________________________ DATE RECOM MENDED
Disbursements certified pursuant to Section 37 of the Financial Administration Act, 1977. Processing of
attached transactions as being in accordance with this Act and the directives prescribed thereunder.
ACCOUNTING OFFICER DATE AUTHORIZED
DATE PROCESSED BY IMAGIS------------------ CHECKED BY-----------------

Page No.00522
Invoice W orksheet
IRVQECBHQ:
Vendor Muffler
Mutitipatty
Address
Remit MSG
Amount
~i
Pymt Due Bata
Accamt Goitre
Preeared By □ .

Page No.00523
Government Application for Disaster Recovery Assistance
Alberta Emergency Management Agency
The personal information being collected on this form is required to appropriately administer die Disaster Recovery Program. The information is being collected under the
authority o f section 33(c) o f the Freedom of Information and Protection o f Privacy (FOIP) Act and will be managed in accordance with the privacy pmvisions in the FO IP Act.
If you have any questions concerning the collection of this information, please contact the Program Office at 780-422-9000.
M u n ic ip a lity , F irs t N a tio n s an d G o v e r n m e n t D e p a rtm e n t In fo rm a tio n

Legal Name of Municipality, First Nations or Government Department
Mailing Address
Telephone Number Fax Number
Name of Chief Elected Official/Title Name of Administrative Official/Title
Name of Contact Title of Contact
Time Frame of Evenl

Start Date (y y y y -m m -d d ) Start Time End Date ( y y y y -m m -d d ) End Time
Type of Event: (s e v e r e r a in s to r m , fire, o v e r la n d flo o d in g , s e v e r e w in d , e tc .)
Location/s of Event:
Description of W eather Leading up to the Event:
Has this type and scale of event occurred before? If so, when:
□ Yes □ No
In respect to infrastructure damage, what caused the damage: (h a il, p o n d in g , o v e r la n d flo o d in g , w in d , e tc .)
Has environmental data been attached: (a tta c h in g this d a t a w ill a s s is t w ith a c c u r a c y o f d e te r m in in g a n d m e a s u r in g th e e v e n t d a t e s , ty p e a n d s c a le )
□ Yes □ No
Does your municipality/first nation have bylaws/ band council resolutions (BCRs) restricting development in areas deemed a flood risk?
f~1Yes Q No If Yes, please attach a copy with your application.
AEMA1376 (2013/05)
Page No.00524
IB H ffE B E liE IS in B n T S ffllB IS ilH B H W g ^ S n iB H IS B (Please attach additional pages if space below is not sufficient)
Emergency Operations General
Description:
Estimated $ Amount
Infrastructure Damage: The locations should General

be identified using Latitude and Longitude, Description:
National Topographic System (NTS)
coordinates (Dlease indicate the datum
used) o r an Address.
Estimated $ Amount Locations of

Infrastructure
Damage:
Small Business & Institutional Loss General

Description:
Estimated # of Cases
Residential Loss General

Description:
Agricultural Loss General

Description:
C e rtific a tio n
Chief Elected Official Date ( y y y y -m m -d d )
Chief Administrative Official Date ( y y y y -m m -d d )
AEMA Field Officer Date (y y y y -m m -d d )
1 Please see page 2 fo r explanatory notes
AEMA1376 (2013/05)
Page No.00525
Please read all instructions before filling out application
Instructions
To be eligible for response and recovery payments through an approved Disaster Recovery Program, your
application must be received by the Alberta Emergency Management Agency (AEMA) within 90 days of the event.
Disaster Recovery Programs may be initiated when:
• An event is considered extraordinary
• Insurance is not reasonably or readily available
• The event is wide spread
For complete copies of the Disaster Recovery Regulation and Disaster Assistance Guidelines please visit the AEMA
website or contact your AEMA Field Officer.
If you have been adversely impacted by an environmental event and are requesting assistance from the Provincial
Government, please include as much detail as possible.
A state of local emergency does not have to be declared in order to receive financial assistance under a Disaster
Recovery Program.
Municipalities, First Nations or Government Departments may be eligible for the following:
• Emergency Operations costs directly related to the event;
• Repairs to public facilities damaged by the event;
• Repairs to infrastructure such as streets, roads, bridges, wharves, docks and water management works;
• Repairs to government and public buildings such as schools, hospitals, public libraries and public
recreational facilities;
• Incremental costs incurred in responding to and repairing damage resulting from the event, such as
employee overtime; regular salaries of employees are NOT considered an incremental cost.
Damage to private property is considered eligible under a Disaster Recovery Program if insurance was not
reasonably and readily available.
Damage estimates should include a Residential, Small Business, Agricultural and Institutional component as well
as a general estimate of infrastructure damage that has occurred within the Municipal or First Nations boundaries.
All estimates must be submitted on this form to the Alberta Emergency Management Agency within 90 days of the
event.
AEMA1376 (2012/05)
Page No.00526
Explanatory Notes
E v e n t D e ta ils
1. A "State of Local Emergency" does NOT need to be declared in order for a Municipality or First Nations to request assistance
through a Disaster Recovery Program. Information on fatalities, injuries, evacuees and whether or not a State of Local
Emergency was declared are required to understand the scope of the event.
2. In order for an event to be considered for a Disaster Recovery Program, it must be deemed extraordinary, widespread and
uninsurable as determined by the criteria listed in the Disaster Recovery Regulation (AR 51/94). Municipalities or First Nations
should provide any environmental data and as much evidence and documentation as possible regarding the damages
resulting from the event.
D a m a g e D e s c rip tio n
1. The general principles governing the assistance available to applicants are:
• The program is intended to assist with the resumption of people's lives in the wake of a disaster. Disaster Recovery
Programs serve as a safety net, providing financial assistance for requirements essential for day-to-day living, but are not
intended to provide full compensation for all losses.
• Damaged property can only be restored to pre-disaster functional condition.
• Only uninsurable losses are eligible for disaster recovery assistance. A property owner who chooses not to insure losses for
which insurance was readily and reasonably available, will not be eligible for disaster recovery assistance.
2. Emergency Operations Estimate. Provide a general description of the activities involved for which incremental expenses have
been incurred (e.g. Emergency Operations Centre or Application Registration Centre, cleanup costs, etc). Regular employee
expenses are not considered to be incremental.
3. Infrastructure Damage Estimate. Provide a general description of the infrastructure damage that has resulted from this event.
This can include repairs to health and sanitation facilities, repairs of streets, roads, bridges, wharves, docks and water
management works, repairs to government and public buildings and their related equipment, as well as facilities such as
schools, hospitals, public libraries and public recreational facilities. Please provide a sample of location/s of infrastructure that
experienced significant damage. The locations should be identified using Latitude and Longitude, National Topographic
System (NTS) coordinates (please indicate the datum used) or an Address.
4. Small Business and institutional Loss Estimate. Provide a general description in terms of numbers and scope of businesses
and institutions that have been impacted by the event. The definition of an eligible small business is where the owner/operator
(s) is the day-to-day manager of the business and derives at least 20% of his/her income from the business operation. All
sources of income are included in determining eligibility.
5. Residential Loss Estimate.Provide a general description in terms of numbers and scope of residences that have been
impacted by the event. Only the applicant's principal residence is eligible for assistance, and only for uninsurable damage.
6. Agricultural Loss Estimate. Provide a general description in terms of numbers and scope of the farms that have been impacted
by the event. Eligible applicants are owner(s)-operator(s) that is/are acting as a day-to-day m anagers) and own(s) at least 50
percent of the business.
S ig n a tu re s
Any application received that does not have the signatures of the Chief Elected Official, the Chief Administrative Officer and the
AEM A Field Officer will be returned.
A s s is ta n c e
For assistance in completing these estimates, please contact:
A) Your Alberta Emergency Management Agency Field Officer, or
B) Alberta Emergency Management Agency

Recovery Program
14515-122 Avenue
Edmonton AB T5L 2W4
310-0000 toll free, then by dialing 780-422-9000
AEMA1376 (2012/05)
Page No.00527
Disaster Recovery Program Project Details
Municipal Cost
# o f Hours Claimed (no
Vendor Invoice Date Invoice # (Units) Rate GST) Activity Project Comments
1 /8 /2 0 1 6 Page 1
Page No.00528
Municipal___________________
Disaster Recovery Program
Project Cost Summary Sheet
Project Number:_____
TO RESTORE/REPLACE TO PRE-EVENT CONDITION/PERFORMANCE
Name of Project:_____________________________________________
Location:_________________________ ____________________________________
Damage Description:______________ _______________________________________
Event Date: Completion Date:
Activity Municipal Claim DRP Staff to Complete

Estimated Cost Actual Cost Eligible Provincial Eligible Federal
Engineering
Materials
Labour
Equipment
Contracts
Project Total:
Reviewed and certified that the actual costs paid are those required to restore the works to pre
disaster performance or condition.
Municipal Officer
DD/MM/YYYY

Page No.00529
Primary Applicant Declaration
I, _ as the Primary Applicant, declare th at all information I am

providing is tru e and I will advise the Disaster Recovery Program office immediately if there are any changes to the
information I have provided.
I understand th at the personal information being collected on these forms is required fo r the purpose of
administering my application under the Disaster Recovery Program and th at its collection is authorized under
Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act.
I understand th at all personal information th a t I am submitting, including personal contact information, insurance
coverage inform ation, tax assessment inform ation, business records, a n d /o r other personally identifying
information such as quotations, invoices, receipts, permits, w ork status docum entation, will be managed in
accordance w ith the privacy provisions of the FOIP Act, and may need to be disclosed to other parties during the
administration of my application. Any disclosure o f my personal information will be done in accordance with
Section 40 o f the FOIP Act.
I understand th at if my grant application is approved, my name, the grant program and the am ount of the grant I
receive may be published on the Government of Alberta Grant Disclosure Portal pursuant to section 4 0 (l)(b ) and
(f) of the FOIP Act.
Primary Applicant Signature Date (m m /dd/yyy)
Witness Signature Date (m m /dd/yyy)

Page No.00530
ID Verification Form
ID Provided: Q Yes I 1No
ID Type: _____________________
ID N um ber: _____________________
Name on ID: _____________________
Gender: □ M ale □ Female
Address: ____
ID verified in Person: I lYes f~ lN n
V erified by: _________________________

Print name
Signature

Page No.00531
Government FN Application Number
Of Alberta ■ Statement of Loss and Damage (First Nation)

D is a s te r R e c o v e r y P ro g ra m
P R O G R A M _________________________________________________ D A T E O F L O S S _________________________ P A G E 1 o f ______

(d d /m m /y y y y )
Please check one only: Q Hom e O w ner Q Tenant S m a ll B u s i n e s s Q A g r ic u ltu r e Q In s titu tio n
(Band Registered Occupant)
A P P L IC A N T IN F O R M A T IO N
Name(s) (First and Last and Middle Initial) Band Name
Alternate Names Used (Aliases) Full Name of Spouse
Business Name (Only if dam age is to an income property, business property, farm or institution)
Mailing Address Street o r P O Box City, Town or Village Province Postal Code
Home Telephone Number Business Telephone Number Cellular Telephone Number Facsimile Telephone Number
( ) ( ) ( ) ( )
E-mail Address Government Issued Photo ID
A L T E R N A T E C O N T A C T P E R S O N IN F O R M A T IO N
Name Home Telephone Number Business Telephone Number Cellular Telephone Number Relationship
( ) ( ) ( )
D A M A G E D P R O P E R T Y IN F O R M A T IO N Is this house owned by the band? I I Yes I I No

( F o r a g r ic u lt u r e a p p lic a n t s , in t h e e v e n t o f m u lt ip le d a m a g e d p r o p e r t ie s , p l e a s e lis t e a c h o n e o n t h e c o n t in u a t io n p a g e o f th is f o r m .)
Urban Address - Band House Number City, Town or Village Postal Code
Damaged Property Address • Rural Q TR SE C TW P RGE W E S T of
M D /C o u n ty ___________________________ Rural Address_________

Total # of persons permanently living at this location at the time of the event. Housing Identificaton Number
( P l e a s e lis t t h e n a m e s o f t h e a d u lt s o n t h e c o n t in u a t io n p a g e o f th is f o r m .)
it o f A D U L T S ________ # of CHILDREN
IN S U R A N C E IN F O R M A T IO N Is the dam aged property insured? I I Yes I I No

Name of Insurance Broker/Agent Telephone Number
( )
Date Broker/Agent was Notified Action Taken by Insurance Company
D e s c r ib e w h e n a n d h o w y o u w e r e im p a c t e d a n d lis t a l l lo s t a n d d a m a g e d it e m s o n t h e c o n t in u a t io n p a g e o f th is fo r m .
I, the Owner / Tenant / Authorized Agent, declare that all the information I am providing is true. I authorize the Minister of
Municipal Affairs and the Program Administrators to contact any third party for information relevant to this application.
Signature of Applicant Date Signature of Witness Date

In fo rm a tio n c o lle c te d is f o r t h e p u rp o s e s o f th e D is a s t e r R e c o v e r y P r o g r a m in a c c o r d a n c e w ith th e E m e r g e n c y M a n a g e m e n t A c t. A lb e r ta M u n ic ip a l A ffa ir s ’
c o lle c tio n o f th is in fo rm a tio n is g o v e r n e d b y th e A lb e r ta F r e e d o m o f In fo rm a tio n a n d P r o te c tio n o f P r iv a c y A c t. Q u e s tio n s a b o u t th e c o lle c tio n o f in fo rm a tio n c a n b e
d ir e c te d to A lb e r ta M u n ic ip a l A ffa irs , A lb e r ta E m e r g e n c y M a n a g e m e n t A g e n c y , 1 4 5 1 5 - 1 2 2 A v e n u e , E d m o n to n , A lb e r ta T 5 L 2 W 4 .
O F F IC E U S E O N L Y
1 1 Reviewed Program 1 1 Send for Evaluation P I Business Elidible

Handout With Applicant Initials Date Initials Date
Date Received
1 1 Special Circumstances application (specify):
Attempted Contact Dates:
Comments:
AEMA1241 (2011/08)
W h it e - A L B E R T A E M E R G E N C Y M A N A G E M E N T A G E N C Y C a n a r A '^ e ^ V H t ^ ^ l 1d ffairs
S tatem ent of Loss and D am age - Continued A p p lic a tio n N u m b e r FN
LOSS AND DAMAGE DESCRIPTION Page____ of
(Briefly describe how & when damage occurred)
EVACUATION At anytime during this event were the residents of the damaged property evacuated? Q Yes O No
RESIDENTS
1. H o w m an y p erm an ent residents reside in th e b asem en t? _________
2. List th e n am es o f all p erm an e n t residents living at th e d am ag ed p ro p erty a t th e tim e o f th e event (First + Last)
1. 7.
2. 8.
3. 9.
4. 10.
5. 11.
6. 12.
ITEMS LOST OR DAMAGED
1. 12.
2. 13.
3. 14.
4. 15.
5. 16.
6. 17.
7. 18.
8. 19.
9. 20.
10. 21.
11. 22.
if needed, additional items may be listed on a separate sheet and updated at the time of evaluation.
Signature of Applicant Date Signature of Witness Date
W h it e - A L B E R T A E M E R G E N C Y M A N A G E M E N T A G E N C Y C a n a ry ib e P ty M A n ^ 3 T Q Ifiirs in fo r m a t ^ q U e S ? 2 0 ^ 0 0 1 8
Page No.00533
Information Regarding the Completion of the Statement of Loss and Damage
Complete the forms carefully as this is your formal declaration of losses. Print legibly to ensure the information
is correctly understood.
Application Type - Check only one box. Indicate if you are the Homeowner (Band Registered Occupant) and
were personally residing in the home at the time of the event, or a Tenant with only damages to the contents which
you own. Businesses should check off the ‘Small Business' box. Farms should check off the ‘Agriculture’ box.
Institutions include schools, community centers, churches or other Not-For-Profit organizations.
Applicant Information - The owner of the damaged property needs to be identified. If the damaged property is
owned personally, then indicate your first and last name, mailing address and telephone contact details. If the
damaged property is owned by your business, then indicate the name of the business and print your name as the
contact person in the first line in this section. Do not add a business name if the property is not owned by the
business.
Alternate Contact Person - If you are not available and wish to direct our office to deal with an “Alternate” contact
person, please provide the details.
Damaged Property Address - You must supply the location where our evaluator can schedule a visit to evaluate
the damages. If the damaged property is located at the same address as the mailing address, then simply check
the box. If your mailing address is for your personal home and you are applying for assistance for a separate rental
property, then note the damaged rental property address. If your mailing address is a postal box or you are located
in rural Alberta, you will need to provide the street address or legal land description. In some cases a lot, block and
plan may be required if there is no street address.
Insurance Information - You are required to obtain written, signed confirmation from your broker/agent that your
insurance policy does not cover the loss. Please have this document available for the evaluator during the site visit.
The letter must include the name of the insured party, company letterhead, damaged property location, date(s) of
loss, type of loss being reported and the outcome of your insurance claim. The letter must contain an explicit denial
of coverage for the specific type of damage incurred. We require a legal land description of the damaged property
as a post office box does not identify the location. If your insurance claim is initially denied and then subsequently
reversed, you must contact the program office to advise of the change. On this form, provide contact information for
your insurer, the date you contacted your insurer and the outcome.
Declaration - You must sign and date both forms and have them witnessed as this is your formal declaration of
losses. You are declaring that the information contained on these forms is true and accurate to the best of your
knowledge. You aiso commit to advise the program office of any changes to the information you are providing.
Page Two - Page two provides an opportunity to briefly describe when and how you were impacted. Please note
the date when you were first impacted, what happened and what you did to recover or deal with the damage. It is
important to take photos, keep receipts and be prepared to assist our evaluation team in reviewing your situation.
You should list all the significant property which was damaged. Only essentials are eligible for assistance, but your
complete list should be submitted. Items can be added by our evaluator when they meet with you on-site.
Program Office - You are welcome to contact the Program Office at any time for an update on your application or
evaluations. The mailing address and telephone contact information is:

.14515 - 122 Avenue
E d m o n to n , A lb e r t a.T5L 2W4
T o ll F re e P h o n e : 1 -8 8 8 -6 7 1 -1 1 1 1
F ax N u m b e r: 1 -7 8 0 -4 2 7 -1 2 6 2
Please forward the white and yellow copies of these forms and retain the pink copy for your records. If you have
additional information it can be provided on separate sheets.

Page No.00534
First Nation:_____________________

Project Cost Summary Sheet
Project Number:_____
TO RESTORE/REPLACE PRE-EVENT CONDITION/PERFORMANCE
Name of Project:______________________________________________________
Location:____________________________________________________________
Damage Description:____________________________________________________
Event Date: Completion Date:
Activity First Nation Claim DRP Staff to Complete

Estimated Cost Actual Cost Eligible Provincial ' Eligible Federal
Engineering
Materials
Labour
Equipment
Contracts
Project Total:
Inspected by:
Comments:
Reviewed and certified that the actual costs paid are those required to restore the works pre-event
performance or condition.
First Nation Authorizing Officer
DD/MM/YYYY

Page No.00535
BCR No.
D eclaration of a State of Em ergency

Band C ouncil Resolution
W hereas : an emergency exists within the First Nation of

due t o ___________________________________
(enter a description of the nature and location of the emergency).
W hereas : our First Nation has exceeded all resources and therefore notify AANDC
and the Province of Alberta that additional support and resources may be
required to assist our Community.
W hereas : the Chief and Council understand policies and provisions for
compensation and some costs will be the responsibility of the First Nation
and Council will ensure documentation and records are available for
recovery assessment.
W hereas this notice may be terminated at any time by the Chief and Council, or
after seven (7) days the notice will automatically expire. If necessary, this
notice will be renewed every seven (7) days until the event is over.
T herefore Be It R esolved
the Chief and Council declare a State of Emergency effective immediately.
Executed th is_____ day o f________________________ 2013.
Chief Council
Council Council
Council Council
Council Council
EDMONTON# 1221953 - vl
Page No.00536
^/Qdberbtai Government Statutory Declaration Lost or Missing Receipts
The collection of personal information on this form is required to administer your claim under the Disaster Recovery Program and is
authorized under section 33(c) of the Freedom o f Information and Protection o f Privacy (FOIP) Act. All personal information will be
managed in accordance with the privacy provisions under the FO IP Act. If you have any questions about the collection of this information,
please contact the Disaster Recovery Program Branch, 14515-122 Avenue NW, Edmonton, AB T5L 2W4.
Full Name of Applicant
Of
Address
do solemnly declare that:
1. I have suffered losses and/or damages to my contents and/or property as a result of the
Event Name
2. I have applied for financial assistance for losses and/or damages to my contents and/or property under the
Event Name
Disaster Recovery Program and in accordance with the D is a s t e r R e c o v e r y R e g u la tio n and the Alberta Disaster
Assistance Guidelines.
3. The following is a list of losses and/or damages which I paid to replace and/or repair post-event and was required to
have receipts for in order to obtain financial assistance. I did originally have receipts but no longer have the receipts in
my possession or know the location of those receipts.
4. l have made all efforts to get duplicate copies of these receipts or invoices, as follows:
5. I have made all efforts to get copies of cancelled cheques representing payment for these items as follows:
6. After conducting a thorough and diligent search to the best of my abilities, I confirm I am not able to get duplicate
copies of these receipts or invoices, and I am not able to get copies of cancelled cheques to represent payment for
same.
7. I make this Declaration in lieu of providing receipts and/or invoices and/or cancelled cheques as required under
Schedule 2 and Schedule 3 of the Disaster Assistance Guidelines.
8. I further declare that I understand there may be legal penalties for providing false or misleading information on which
the Disaster Recovery Program relies to determine my eligibility for financial assistance under the D is a s t e r R e c o v e r y
R e g u la tio n and the Alberta Disaster Assistance Guidelines.
AND I MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true and knowing that it is of the same effect
as if made under oath.
DECLARED BEFORE ME at the ____________________ of

Signature of Applicant
, in the Province of Alberta,
Ccrrrr-is$ien*»r *c' Stam p
th is _______ day of .20
A Commissioner for Oaths or Notary Public in and for Alberta

(Also indude printed or stamped name and expiry date)
Alberta Municipal AffairsTnformation Request 2015-R-0088
A E M A I0934 (2015/07)
Page No.00537
14515- 122 Avenue
Edmonton, AB T5L 2W4
ALBERTA Phone: 780-422-9000
EMERGENCY Fax: 780-422-1549
AL E RT
Government of Alberta u
ALBERTA EM ERG ENCY ALERT

D E S IG N A T IO N F O R M
Nominating Municipality/Community/Organization/Agency/First Nations:
LEGAL NAME OF M UNICIPALITY/ COMMUNITY /

ORGANIZATION / AGENCY/FIRST NATIONS
ADDRESS
POSTAL CODE
EMAIL
T E LE P H O N E ( FAX ( )
The above organization hereby applies for access to Alberta Emergency Alert by designating on its
behalf the following individuals as authorized users for the system:
D e s ig n e e #1
FULL NAME:
POSITION:
MAILING ADDRESS {if different from above):
CITY: PROV: POSTAL CODE:
EMAIL:
BUSINESS PH: FAX:
BUSINESS CELL: PERSONAL CELL:
NOMINEE WILL ATTEND

TRAINING SESSION IN : AT: ON:
Municipality Time Date (dd/mm/yyyy)
Alberta Emergency Alert

Designation Form Page 1 of 4

Page No.00538
14515 - 122 Avenue
ALBERTA Edmonton, AB T5L 2W4
Phone: 780-422-9000
ALERT
Govornment ol Alberta ■
Designee #2
FULL NAME:
POSITION:
MAILING ADDRESS (if different from above):
EMAIL:
BUSINESS PH: FAX:
NOMINEE WILL ATTEND

Municipality Time Date {dd/mm/yyyy)
Designee #3
FULL NAME:
POSITION:
EMAIL:
BUSINESS PH: FAX:
NOMINEE WILL ATTEND


Designation Form Page 2 of 4

Page No.00539
14515-122 Avenue
Edmonton, AS T5L 2W4
ALBERTA Phone: 780-422-9000
ALERT
Designee #4
FULL NAME:
POSITION:
EMAIL:
BUSINESS PH: FAX:
NOMINEE WILL ATTEND

We acknowledge that the above individuals will not have access to the system unless they have attended the
training session set forth by Alberta Emergency Management Agency, have fulfilled the requirements identified at
the time of training and signed an authorized user agreement. Only designated individuals specified on this form
shall be allowed access to Alberta Emergency Alert.
We hereby confirm that we are authorized officials for this municipality, community, organization, First
Nations or agency and that we have the appropriate authority to designate the above persons as Authorized
Users of Alberta Emergency Alert by signing this form.
Please ensure that tw o senior officials

from the above designating body sign this form below
PRINT NAME PRINT NAME
PRINT POSITION PRINT POSITION
Signature Signature
Date Date
Atberta Emergency Alert

Deslg nation Form Page 3 of 4

Page No.00540
14515 - 122 Avenue
Phone: 780-422-3000
AL ERT
PLEASE MAIL OR FAX THIS FORM

AS SOON AS POSSIBLE PRIOR TO THE TRAINING SESSION TO:

14515- 122 Avenue
Edmonton, AB T5L 2W4
Office Ph. (780) 422-9000
Fax (780) 422-1549
Email alberta.emergency.alert@qov.ab.ca
The persona] information provided on this form is being collected in support of the Alberta Emergency Alert Program. The
collection is authorized under section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act and will be
managed in accordance with the privacy provisions within the FOIP Act. If you have any questions about the collection of this
information, please contact the Alberta Emergency Management Agency in writing to 14515 - 122 Avenue, Edmonton, AB,
T5L 2W4 or by telephone at (780) 422-9000.

Designation Fonn Page 4 of 4

Page No.00541
14515- 122 Avenue
EMERGENCY Phone: 780-422-9000
ALERT Fax: 780-422-1549
G o ve rn m e n t o f A lb e r ta ■

Authorized User Agreement
Complete and sign 2 Copies. Hard one into your Trarner (or fax to 780-422-1549). Keep one copy for yourself.
PLEASE PRINT
Circle one: Mr. I Ms. / Mrs. / Miss / Dr.
First Nam e:___________________________ Last Nam e:____________
Nominating Community/Organization/First Nation: __________________
Your Municipal/Agency/First Nation Position:_______________________
TELEPHONE NO'S: B usiness: (___ )__________________ H om e: (___ )______
B u sine ss Cell: ( )______________ P ersonal C ell: (____ )

(Fill in as many " "
as possible) Fax: f )______________________ A lte rn a te : ( )
EMAIL: W o rk :____________________________________ H o m e :_______________
Mailing Address: ________________________________________________
C ity:_____________________ Province:________ Postal Code:_____________________
Date of Training:_________________________________
(Authorized User MUST be trained before they are eligible to take part in the program)
THIS FORM MUST BE SIGNED AND DATED AT THE END OF THE AGREEMENT (ON PAGE 3)
"lhe personal information is being collected under die authority of the Emergency Management Act for the administration of the Emergency Management Information
System and/or Alberta Emergency Alert will be managed in compliance with the Freedom o f Information and Protection o f Privacy (FOIP) Act. Any information given
will only be used for mitigation of, response to and recovery from emergencies and testing of the system, If you have any questions, please contact the Alberta Emergency
Management Agency at 14515 - 122 Ave NW, Edmonton, Alberta, T5L 2W4, or by telephone at 780-422-9000.

Page No.00542
14515 - 122 Avenue
Phone: 780-422-900
A L E RT
G o ve rn m e n t o f A lb e rta ■

Authorized User Agreement
Complete and sign 2 Copies. Hand one into your Trainer (or fax to 780-422-1549). Keep one copy for yourself.
1. I acknowledge that l have been appointed as an Authorized User of Alberta Emergency Alert
by and on behalf of the municipality, First Nation, community or agency as noted above (also
confirmed upon completion of an Alberta Emergency Alert Designation Form).
2. I understand that I must renew my appointment in a manner as required by the Alberta

Emergency Management Agency annually. I understand that if I do not renew my appointment
as required, I may be removed as an Authorized User of the Alberta Emergency Alert system.
3. ! hereby agree that my business and personal contact information shall only be used by the
Alberta Emergency Management Agency or other Government of Alberta Emergency
Management Partners as legally authorized by the Alberta Emergency Management Agency
for the purposes of notification of, mitigation of, response to and recovery from emergencies
and for testing. Government of Alberta Emergency Management Partners include those
individuals and departments that work within the Government of Alberta and have a role to play
in emergency management, or when a disaster occurs.
4. When activating Alberta Emergency Alert, I shall follow the guidelines of the “Authorized User
Handbook”, and all other guidelines issued for the use of Alberta Emergency Alert.
5. I shall be personally responsible for all passwords issued to me for purposes of activating
Alberta Emergency A le r t, including:
a) ensuring receipt of, and confirming the initial and continuing viability and accuracy of my
access by monthly log-ons into the practice mode of Alberta Emergency Alert;
b) ensuring the privacy, security and safe custody of my passwords, including but not limited
to, ensuring that my passwords are not given out, loaned or made available to any other
person, and;
c) providing immediate notification to the Alberta Emergency Management Agency, should my

password be compromised, lost, stolen or suffer any other breach of security.
6. I shall notify the Alberta Emergency Management Agency and the

community/organization/First Nation for which I have been appointed an Authorized User
should I leave my position with that municipality or for any other reasons become unable to
serve out the term of this appointment.
7. I agree that I shall make full disclosure to the Alberta Emergency Management Agency of all
actions taken, communication given and all other information pertinent to use of Alberta
Emergency Alert should I activate it for any reason. I will make this disclosure each time I
activate Alberta Emergency Alert and upon receiving a request by the Alberta Emergency
Page 2 o f 3

Page No.00543
14515 - 122 Avenue
Phone: 780-422-900
ALERT
G o ve rn m e n t o f A lb e rta i
Management Agency within a reasonable time from activation

of Alberta Emergency Alert.
8. I understand that, if I activate Alberta Emergency Alert, all my actions leading up to and arising
there from will be subject to review by the Alberta Emergency Management Agency.
9. As a condition of my use of Alberta Emergency Alert, I warrant to the Alberta Emergency

Management Agency that I will not use Alberta Emergency Alert for any purposes that are
unlawful or prohibited by these terms, conditions and notices. I will not use Alberta Emergency
Alert in any manner which could damage, disable, overburden, or impair the public, the Alberta
Emergency Management Agency or interfere with any other party's use of Alberta Emergency
Alert.
I make these undertakings and agreements in full understanding of the role of an Authorized User for
Alberta Emergency Alert. Unless otherwise specified herein, this agreement, together with the completed
Designation Form constitutes the entire agreement between the Authorized User and the Alberta
Emergency Management Agency with respect to Alberta Emergency Alert and it supersedes all prior or
contemporaneous communications and proposals, whether electronic, oral or written, between the
Authorized User and the Alberta Emergency Management Agency with respect to Alberta Emergency
Alert.
The effective date of my appointment as an Alberta Emergency Alert Authorized User shall be dependent
upon the Authorized User demonstrating success, knowledge, and understanding of the Alberta
Emergency Alert system within a designated training environment as well as the receipt by the Alberta
Emergency Management Agency of the completed Designation Form and this Authorized User Agreement
document,
(Contact’s Signature) (Date)
Page 3 of 3

Page No.00544
REQUEST FOR MAPS OR MAP SERVICES
Please provide the following information to Kevin McClement via e-mail or in person:
Name of Requester:
□ Print □ Electronic (PDF) □ Software Addition (To GIS Explorer)
I 18 1/2" x 11"
| | 8 1/2" x 14"
| | 11"x 17"
| 117" x 22"
| 122" x 34 "
| 134" x 44"
Number of copies:
Area to map (provincial level, county level, city level):
Main objective (what do you NEED to see on the map): *O ther items may be added at the discretion
of the GIS anaylst to enhance the information provided.
Audience for the map (internal, POC Duty Officers, Field Staff, etc.):
URGENCY: j ^ H i g h (Activation or Emerging Incident) | |Low (planning, daily work, meetings)
□ vip
Date needed by (minimum three business days):
***P lease note we will endeavour to complete your request as soon as possible but please plan for
three to five business days for LOW urgency requests where
Field Operations
V acation/O T /TO IL - Request Form
**AII sections must be completed**
Instructions for completion:

1. Give as much advanced notice as possible.
2. Indicate the exact number of days/hours you will be away from the office.
3. Forward the completed request to Crystal Clarke to obtain Manager’s approval prior to the beginning of the time off.
Name: Date of Request
Requested Carried Forward

Vacation (Hrs)
Toil (Hrs)
Flex (Hrs)
Personal (Hrs)
From To Number of Hours State actual hours {ie 8:15 to Noon & 1:-4:30)
(Month/Day/Yr) (Month/Day/Yr)
Remarks:
Does the above request fall within your scheduled “On Call” Time? ______
Who will be providing coverage for your area while you are away? _______
Supervisor’s Signature: Date:
*Crystal Clarke or Tracy Tischer will update Agency Vacation Calendar

Page No.00546
Aa \ L A lbe rta Em ergency
M anagem ent A g e n cy
AEMA Emergency Lamp Activation Report
A B D L A N T ic k e t ID:
D ate ( D D -M m m -Y Y Y Y ) T im e (h h m m )
Report filled by (name) Date of Call Time of Call
Driver Vehicle ID Number Contact Number
Location Moving (Y / N) KPH
Reason for emergency light activation
Duration of emergency light activation
POC Manager Notified (name) Notifying PDO Date/Time
Central Operations Director Notified (name) Notifying PDO Date/Time
PRCC Notified (yes / no) Notifying PDO Date/Time
Information Logged on ABDLAN (yes / no) Logged By Date/Time
Comments/Notes/Issues

Page No.00547
Alberta Emergency
yQ&bwbcyJi Management Agency
PROVINCIAL OPERATIONS CENTRE

Event N otification
This Event Notification is intended to improve internal situational awareness of a potential emerging situation and may contain preliminary or
unconfirmed information regarding a potential or emerging situation/incident and the current actions being undertaken by organisations. Some
fields within the report may be blank as this information is either unknown or being developed at the lime the report was issued.
Due consideration should be given before taking any action.
Any questions pertaining to the content o f this document should be addressed to the
AEMA POC Manager - Gordon Beagle or the Director Central Operations - Stephen Carr.
Please do not distribute or disseminate this document. It is not intended for distribution external
to the Government of Alberta.
Event Title:
Event Date
Event Time (hhmm):
(DD-Mmm-YYYY):
ABDLAN Ticket # Report U
Location (CIS product may also be attached to ticket)
jV IL A ( s):
MP(s)
Event Summary:
Current Responses and Actions

Local Authorities:
State of Local Emergency (SOLE):
Emergency Coordination Centre (ECC):

Page No.00548
Evacuations:
Industry:
Government of Alberta (GOA):
Alberta Emergency Management Agency (AEMA):
Alberta Emergency Alert:
Health Impacts:
First Nations Impacts:
Media Coverage:
AEMA POC Assessment:
PDO Notifications:
r r
Executive Notification Executive Director

Page No.00549
Distribution List Provincial OPS
r r r r
Director Central OPS Plans Manager FO Manager FNFO Manager
r r r r
POC Manager EMO Plans FOs FNOs
r r r r
I’ DOs CMOs On Call FO On Call FNFO
r r r r
Other BCOs OFC On Call AEA WNC
Information Source & Time of Receipt:

Time (hhtnm): Date
Source:
(DD-Mmm-YYYY):
An update to this Event Notification will be issued if required or should the event result in the
elevation of the POC Operational Level, a COPR will be distributed to Public Safety Stakeholders.

Page No.00550
A *. j Alberta Emergency
Jtl Management Agency

Severe W eather N otification
This Event Notification is intended to improve internal situational awareness of a potential emerging situation and may contain preliminary or
unconfirmed information regarding a potential or emerging situation/incident and the current actions being undertaken by organisations. Some
fields within the report may be blank as this information is either unknown or being developed at the time the report was issued.
Any questions pertaining to the content of this document should be addressed to the
Event Title:
Event Date
Event Time(hhmm):
(DD-Mmm-YYYY):
AB DLAN Ticket # Report #
Location (GIS product may also be attached to ticket)
MLA(s):
MP(s)
Event Summary:

Local Authorities

Page No.00551
Evacuations:
Industry:
Health Impacts:
Media Coverage:
PDO Notifications:
r r

Page No.00552
r r r r
Director Central OPS Plans Manager EO Manager FNFO Manager
r r r r
POC Manager EMO Plans EOs FNOs
r r r r
PDOs CMOs On Call EO On Call FNFO
r r r r
Other BCOs OFC On Call AEA WNC

Time (Iihmm): Date
Source:
(DD-Mmm-YYYY):
An update to this Event Notification will be issued if required or should the event result in the

Page No.00553
Alberta Emergency
Management Agency

Flash Update - Event N otification
This Flash Update is intended to provide important / imperative information between Event Notifications to improve internal situational awareness
and may contain preliminary or unconfirmed information regarding the event.
Event Title:
Event Date
Event Time (hlimm):
(DD-Mmm-YYYY):
AB DLAN Ticket # Report U
Event Update

Date
Source Time (hlimm):
(DD-Mmm-YYYY):
A more detailed update will be provided in the next Event Notification will be issued if required or
should the event result in the elevation of the POC Operational Level, a CO PR will be distributed to
Public Safety Stakeholders.

Page No.00554
Request for Food Assistance
OPS 3-3
1. BRIEF Description of Problem Encountered:
2. Number of sites to be served:
3. Num ber of Meals to be served:
4. Number of days meals needed to be served:
5. Location(s) of Meals served:
6. Shelter Capacity / Occupancy:
7. Operational Period Dates:
FOOD: (States A ssets Limited Availability)
Bulk Food: (To be cooked / prepared at Shelter)
8. Quantity o f people (not meals) Served Per Meal, daily:
Bulk Food / Ready to Serve: (Prepared meal that may require heating prior to serving)
9. Quantity o f people (not meals) Served Per Meal, daily:
10. Special Needs (explain):

Page No.00555
11. Quantity of people (not meals) Served Per Meal, daily:
12. Dietary (Kosher, Halal, Vegetarian, Allergies, other):
14. Other Needs:

j
FOOD: (Contracted A sse ts - Subject To Availability)
Meals-Ready-to-Eat (MRE)
19. Formula (specify liquid concentrate, powder, or ready-to-serve) Describe:

Page No.00556
20. Quantity of infants (not meals) Served Per Meal, daily:
NON-FOOD ITEMS:
Paper Plates:
21. Quantity Needed Per Day:
Plastic Flatware
Plastic Cu p s

!
Napkins
Plastic Bowls
Trash B a gs
Paper Towels

Page No.00557
W aterless Hand Sanitizer
29. Other:
31. Preparation / Storage capabilities at Feeding Site:
Safety Considerations
1. Ensure information provided on this form as well as ail actions taken in relations to this request is performed by qualified
professionals.
2. Requesting agency assumes all costs unless otherwise noted.
3. It is requestor’s responsibility to notify POC of resource status, (arrival time, idle time, time used, demobilization time before the
actual demobilization, and time released.)

Page No.00558
A j. . Alberta Emergency
Management Agency

Executive N otification
This Executive Notification is intended to improve internal situational awareness of a potential emerging situation
and may contain preliminary or unconfirmed information regarding a potential or emerging situation/incident and
the current actions being undertaken by organisations. Some fields within the report may be blank as this
information is either unknown or being developed at the time the report was issued.
Event Title:
Event Date
Event Time (bhmm):
(DD-IYlmm-YYYY):
AB DLAN Ticket # Report #
Location (GIS product may also be attached to ticket)
MLA(s):
MP(s)
Event Summary:

Local Authorities:

Page No.00559
Evacuations:
Industry:
Health Impacts:
Media Coverage:
PDO Notifications:

Page No.00560
r r r r
Director Central OPS Plans Manager I'O Manager FNFO Manager
r r r r
POC Manager EMO Plans FOs FNOs
r r r r
PDOs CMOs On Call FO On Call FNFO
r r r r
Other BCOs OFC On Cal! AEA WNC

Time (lihmm): Date
Source:
(DD-Mmm-YYYY):
An update to this Executive Notification will be issued if required or should the event result in the

Page No.00561
A lberta Em ergency
M anagem ent A gency
AEMA PROVINCIAL OPERATIONS CENTRE

FIELD OPERATIONS SITUATION REPORT
Prepared By:
Field Officer: P le a se S p ecify J

Event Date
(DD-Mmm-YYYY): t Event Time (hlimm):
(24 hr. d o c k ) 1
Event and Location Information
Name o f Event/Incident/Activity Date (D D -M m m -Y Y Y Y ) Time (hhmm):
Location AEMA Region/FN Region Community
(k it. <6lo n g , o r d e s c r ip tio n )

P lea se S p e c ify | P le a se S p ecify
T3
( i f oilier, p le a s e s p e c ify :)
r
Stakeholder^) Involved
Event Description
E vent / In c id e n t /
A c tiv ity Type: C u r r e n t S itu a tio n :
P le a se S p e c ify 3 P le a se S p e c ify -r
D e s c r ip tio n o f E v e n t /I n c id e n t /
A c tivity :
F a ta litie s In ju rie s P e o p le E v a c u a te d
t o r "n o t k n o w n " r
| U o r "n o t k n o w n " r#
| or "not k n o w n "
Status of Community EOC/ECC(s)
S O L E D e c la re d : D ate (D D -M m m -Y Y Y Y ): T im e (hhm m ):
P lease S p ecify ▼
1 !
A ctiv ated : D a te (D D -M m m -Y Y Y Y ) T im e (hhm m ):
P lease S p ecify ▼
1
Page No.00562
Deactivated: Date (DD-Mmm-YYYY) |Time(hhmm):
Please Specify Sr
. ... . ............! 1............ ....... !
If activated, provide locations):
Reception Centre Activations
Date (DD-Mmm-YYYY): Time (hhmm):

Activated: C Yes C No
1 ........ ....... ____
If activated, provide location(s):
Impact to Critical Infrastructure
Date (DD-Mmm-YYYY) Time(hhmm):

Impact: | Please Specify
1......................... ......
If real impact, provide description:
Impact to Environment
Date (DD-Mmm-YYYY): Time(hhmm):

Impact: | Please Specify
If real impact, answer the following questions:
Description:____________________________
Threat of water contamination? C Yes C No
Type of water affected?

Please Specify
Media Interest ■ ' "" ''. . '
Is there any noticeable media interest? C Yes C No
If yes, what type? Please Specify j*
Current Incident Objectives
1.
2.

Page No.00563
3.
Projected Incident Objectives
1.
2.
3.
Next Operational Update
N e x t U p d a te ? D a te (D D -M m m -Y Y Y Y ): T im e: (hhm m ):
P le a se S p ecify ▼
1
Current Operational Update
F ro m D a te F ro m T im e T o D ate T o T im e
(D D -M M -Y Y Y Y ): (hhm m ): (D D -M m m -Y Y Y Y ): (hhm m ):
1 .......
Additional Resources Required
P eople: I f y e s , p le a se sp e cify w h ic h :
C Yes C No
Equipment: I f y e s, p le a se sp e cify w h ich :

C Yes C No
Estimated Time of Event / Incident Completion
S tatus: C KnownC Not Known D a te (D D -M m m -Y Y Y Y ): T im e (hhm m ):
Weather
G en e ral C o n d itio n s: | P lea se S p ecify -
(‘f o th er, p le ase sp e cify :)
W in d D irection: W in d S p eed : O usting:
| P lease S p ecify -
1
Remarks

Page No.00564
COPR Update Form
1. Key activities completed by your ministry since the last COPR:
2. Key activities currently ongoing within your ministry:
3. Key future activities (planned) by your Ministry:
4. Key Metric(s) to report:
5. Any significant issues at this time?:

Page No.00565
Financial Tracking Form
LO G S 1-1
1. Paid for by:

Please Specify Community(s):
r Community
Please Specify Departments):

P Government Department j
Approved by:
rAEM A
2. Payment Type:
V Purchase Total Purchase Amount: $r
V Rental
Monthly Rental Rate:
Rental Period:
$r
2. Payment Method:
I” Pcard Name on Pcard: [
V Invoice

Page No.00566
Request for Communications Equipment
O P S 1-1
Radio Request
1. Q uantity
2. F req u en cy o r B and R equ ired
3. Is th is a tru n ked system ?

r 1. Y es
r 2. No
4. Is a lic e n s e n eed ed ?
r 1. Y es
r 2. No
5. D id yo u p rev io u sly h ave radio ca p a b ility ?

P 1. Y es
r 2. No
Phone Request
6. Q uantity:
V 1. Fixed site
I” 2. Portable
r 3. Cell**
V 4. Satellite
7. ** If ce ll p ho n es a re requ ested : a re ce ll s ite s a v a ila b le ?

C 1. Yes. Identify service provider:
r 2 . No
8. W ill a c e ll-o n -w h e e ls (C O W ) be n eed e d ?

r 1. Y es
r 2 . No
NOTE: There is a 300 feet cable limit on Internet Protocol (IP) Products

Page No.00567
Internet Capability Request
9. Is th e re p re-e xistin g se rv ic e (i.e. W i-F i)?

r 1. Yes. Please identify:
r 2. No
10. A re p h o n e lin es a v a ila b le ?

r 1. Yes
r 2. No
11. A re p h o n e lin es o p e ra tio n a l?

r 1. Y es
r 2. No
12. Is ca b le T V p ro vid ed ?
r 1. Y es
r 2. No
13. Is c a b le T V w o rkin g
r 1. Yes
r 2. No
M ESA Request
NOTE: 13.5 feet, 45 feet long and 35,000 lbs clearance (travel and on site) is required for this vehicle.
14. W h a t is th e re q u ire m en t?
i
ii
15. Do yo u h ave access to diesel?

r 1. Y es
r 2. No. Estimated time of delivery/distance to diesel:
16. T ech n ical P o in t o f C o n ta c t fo r th is eq u ip m ent: In c lu d e n am e , a re a c o d e /p h o n e n u m b e r, an d a lte rn a te #.
17. S u p p o rt E q u ip m e n t o r S e rv ic e n eed ed: (i.e. re p e ate rs p o rta b ility , lic en se )

Page No.00568
18. Approximate length of time resource is needed:
19. BRIEF Description of Loss / Who Needs Help / Geographic Area For Equipment Use:
Safety Considerations / Notes
1. Ensure information provided on this form as well as all actions taken in relations to this request is performed by qualified
professionals.
3. It is the requestor’s responsibility to notify the POC of the resource status, (arrival time, idle time, time used, demobilization time
before the actual demobilization, and time released.)

Page No.00569
Request for Helicopter and Other Aviation Assistance
O P S 1-2
1. Brief description of problem encountered:
2. Have all local capabilities associated with this resource been exhausted:
r 1. Yes
r 2. No
3. Current resources committed:
4. What type of operation will be performed?

P 1. Fire suppression
P 2. MEDEVAC (medical evacuation)
P 3. CASEVAC (casualty evacuation)
P 4. Hoist/rescue
r
!______ __
P 5. Transport
P 6. Aerial Recon / Observation / photo
P 7. VIP flight of affected area
P 8. Search and Rescue (CASARA)
5. What type of aviation is requested:

P 1. Rotary wing (HELO, helicopter)
f
P 2. Fixed Wing (jet, cargo plane)
P 3. UAV (drone)

Page No.00570
6. Where is the aircraft needed:
I” 1. Search area
P 2. Landing zone in staging area
V 3. Airport (If at an airport, or "named" landing field, please specify:
JT 4. Terrain of Area where aircraft is needed:
7. Any obstructions or hazards of terrain where aircraft is needed?

C 1. Yes (If yes, describe:)
ij
Ii
I____ __ _ ___....._.................................... ....... ....
r 2. No
Coordinates of Helispot (landing zone), pick-up zone, airport or airfield
8. Latitude:
9. Longitude:
10. Notes:
Coordinates of Helispot (landing zone), drop zone, airport or airfield
11. Latitude:
12. Longitude:
13. Notes:
When is aircraft needed?

14. Local time:

Page No.00571
On-scene contact Person:
15. Name:
16. Call sign (if applicable):
17. Radio frequency:
18. Alternate number (cell phone):
professionals.
3. It is requestor's responsibility to notify POC of resource status, (arrival time, idle time, time used, demobilization time before
the actual demobilization, and time released.)

Page No.00572
Request for Light Towers
O P S 1-3___________________
1. Type of light tower needed:
C 1. Self supporting
C 2. Power source required*
2. How many are needed?
3. List locations the light towers are needed:
4. Size of area to be illuminated:
5. Length of time in service:

j_ _ _ _ _ _ _ _
6. Transport of Light Towers (choose one)

C 1. Delivery
C 2. Pickup
7. If pickup, what type of hitch is needed?
8. If pickup, what size of hitch is needed?
9. Do you have a ready supply of fuel to operate the light tower?

r 1. Yes
r 2 . No
10. Please check the type of fuel needed:

I” 1. Gasoline
I” 2. Kerosene
P 3. Diesel Fuel
V 4. Natural Gas (CNG)
V 5. Liquid Propane (LP)
11. If fuel is needed, what is the fuel and the delivery schedule?

Page No.00573
12. Staging Area / Briefing Location:
13. Contact Information (name, phone number, and alt. number):
14. Clear Description of Current Conditions (Environmental, obstacles, and known hazards)
15. Anticipated Demobilization date: .

ri ______ _ ___ _
........ ......... .. ... ......... ..__ .. ;
16. Special Demobilization instructions:

j |
i j
i I
| i
I j
* If external power source is required, refer to and submit the generator request form.
Safety Considerations / Notes
professionals.
3. It is the requestor's responsibility to notify the POC of the resource status, (arrival time, idle time, time used, demobilization time

Page No.00574
Request for Generator Assistance
OPS 1t4
1. BRIEF Description of Problem encountered
2. Is the power:
r 1. Completely Out
C 2. Partially Out
3. Name of Utility Company
4. Has the Uti ty Company given an estimate as to when the power will be turned back on (hours, days, weeks)
5. Is this a replacement for a non-working generator?

r 1. Yes
r 2 . No
6. If yes, what type?
7. If yes, describe the problem with the current generator?
Type/Size of Generator requested
8. Kilowatts (kw)
9. Amps
10. Kilo Volt Amperes (kVa)
11. Phase /Type:

r 1. Single Phase 120/240
r 2. Single Phase 120/208
r 3. Three Phase 120/240
12. Quantity of Generators Requesting

Page No.00575
13. What is the name and type of facility that needs the generator?
14. Number of Floors? (1,2,3,4,5,more than 5, more than 10, more than 25, more than 50)
15. Outside Dimensions (estimated)
16. Do you know of any other Critical Facilities in your area that may also need generators?
r 1. Yes, please list facilities:
r 2. No
17. Facility Use

C 1. Commercial
C 2. Residential
C 3. Mixed
18. Are there Human Services customers impacted?

r 1. Yes, what type?
r 2. No
19. Are there Critical Perishable Items (i.e. Medicine, Blood, Laboratory Studies)?
r 1. Yes, please indicate type:
r 2. No
20. Does the Facility support Emergency Management or Emergency Communications Operations?
r 1. Yes
r 2. No
21. Types of Electrical Load to be supplied

r~ 1. Communications Equipment Other:
V 2. Pump Systems

Page No.00576
1“ 3. Air Conditioning
P 4. Computers
P 5. Lighting
P 6. Refrigeration
22. What is the proximity of the generator to the breaker?(if known, write in)
C 1. Under 100 feet
j_______ _______ _____________ __ _____ __ _________ ______ _____
C 2. Over 100 feet (refer to safety notes)
23. Are Cable Chasers needed to allow vehicles to drive over cables?
r 1. Yes
r 2 . No
24. Is an Electrician needed to hook the generator up?

r 1. Yes
r 2. No
25. List the cables/power distribution boxes on site
26. Are they needed?

r 1. Yes
r 2. No
27. If yes, how many?
28. If yes, required length:
29. Are these cables/switches indoors or outdoors?

P 1. Indoors
P 2. Outdoors
30. Is there a PRE-Hookup

r 1. Yes
r 2. No
31. If yes, what type?

P 1. Double Throw
P 2. Cam Lock
P 3. Already wired for specific generator
P 4. Transfer Switch
32. Are there any other connectors needed?

r 1. Yes, What Type?

Page No.00577
r 2. No
33. Do you have a ready supply of fuel to operate the generator?

r 1. Yes
r 2. No
34. Please select the type of fuel available or needed

V 1. Gasoline
F 2. Kerosene
I” 3. Diesel fuel
F 4. Natural Gas (CNG)
F 5. Liquid Propane (LP)
35. If fuel is needed, what is the delivery schedule?
36. Are additives or a heater needed for the fuel system?

C 1. Yes, what is needed?
____ __ _
r 2 . No
37. Is there a need for hot refueling or can power be safely shut off during refueling?
r 1. Yes
r 2. No
38. Do you have staff to maintain the generator throughout the loan?
r 1. Yes
C 2. No. What is needed?
39. If the Generator is to be used on equipment with electronic controls, is a Ground Rod and Cable needed?
r 1. Yes
r 2. No
40. Is there sufficient space for the unloading and usage space for the generator?
P 1. Yes
r 2. No
41. Is there sufficient equipment for the loading and unloading of the generator?
r 1. Yes .
r 2. No
SAFETY CONSIDERATIONS:
1. SAFETY CONSIDERATIONS: DO NOT PLACE THE GENERATOR INSIDE A BUILDING WITHOUT EXHAUSTING THE
GENERATOR OUTSIDE!
2. ENSURE THE GENERATOR IS HOOKED UP ON THE LOAD SIDE OF THE MAIN BREAKER AND THE MAIN BREAKER IS
OFF. THIS HELPS STOP THE POSSIBLE BACK FEED OF THE POWER GRID!

Page No.00578
3. DO NOT PLACE NEAR BUILDING AIR INTAKES!
4. IF LENGTH FROM GENERATOR TO BREAKER BOX IS OVER 100 FEET, A VOLTAGE DROP MUST BE TAKEN IN TO
CONSIDERATION
5. REQUESTING AGENCY ASSUMES ALL COSTS UNLESS OTHERWISE NOTED

Page No.00579
Request for De-Watering Pump Assistance
OPS 1-5
2. What is the area to be de-watered?

F 1. Residential Occupancies
I” 2. Commercial Occupancies
F 3. Flooded Streets, Parking Lots
F 4. Pond/Lake (impoundments)
F 5. Flooded Low-lying areas
F 6. Known hazmat?
3. Specific item(s) in need of de-watering: please list
Pump Information
4. Size of pump needed (GPM):

i ___ _
5. Quantity needed:
6. De-Watering Depth (estimated):
7. External power source needed?
Type, Size and Length of Hose (suction and discharge)
Suction Side of Pump
8. Type of hose needed:

F 1. Hard suction
F 2. Soft suction

Page No.00580
9. Size required (in inches):
r 1 .1 3 /4 "
r 2 .T
r 3. 2 1/2"
p 4 .3"
p 5 . 4m
r 6 . 5n
r 7 .6"
r 8 .8n
r 9 .12"
10. Length needed (in feet)
11. Hose Thread Type:

I” 1. Pipe Thread
P 2. National Standard
P 3. Storz-lock
I” 4. Cam lock
Discharge Side of Pump
12. Type of hose needed:

P 1. Soft Sleeve
r 2. Hard Pipe (PVC)
13. Size required (in inches):

m 3/4"
r . "
2 2
r 3. 2 1/2"
p 4 .3"
r 5.4"
r 6.5"
r 7.6-
r 8.8"
p a 12"
14. Length needed (in feet)
15. Hose Thread Type:

P 1. Pipe Thread
P 2. National Standard
P 3. Storz-lock
P 4. Cam lock

Page No.00581
16. Approximate distance from area to be pumped to area where water is to be discharged:
j
17. Are there any special filters or strainers needed for the pumps for the water removal?
P 1. Yes
r 2. No
18. If yes, please describe:
19. If yes, quantity of filters/strainers needed:
20. Do you have a ready supply of fuel to operate the pumps?

r 1. Yes
r 2. No
21. Please circle the type of fuel available or needed:

I” 1. Gasoline
F 2. Kerosine
F 3. Diesel fuel
F 4. Natural gas (CNG)
r 5. Liquid Propane (LP)
22. If fuel is needed, what is the fuel and the delivery schedule?
23. Are additives or a heater needed for the fuel system?

r 1. Yes. What is needed?
r 2. No
24. Do you have staff to maintain the pumps throughout the loan of this equipment?
r 1. Yes
C 2. No. What staff is needed?
25. Is there sufficient equipment for the loading and unloading of the pump?
r 1. Yes
C 2. No. What is needed?
26. Is there sufficient space for the usage space for the pump?
C 1. Yes

Page No.00582
r 2. No
SAFETY CONSIDERATIONS
1. Has the flooding receded or begun to recede? You shouldn't be pumping water if it hasn't.
2. During cold weather and long term usage, storage of pumps and hoses in warm facilities needs to be identified.
professionals.

Page No.00583
Shelter Support Request
OPS 2-1_________ ______________ ________________________________________
1. What type of shelter needs support?
I” 1. General Population
it .......... “ .............. " ..... ........ .... ..... . “ I
I” 2. Special Needs
I” 3. Pets
2. Has an NGO been engaged?

C 1. Yes, please specify who?
r 2. No
3. Is this an operated or supported Local Authority shelter?

r 1. Yes
r 2. No
4. Who is responsible for this shelter (i.e. funding, feeding, demob, etc)?
5. List the location (use a separate form for each shelter) and include address and contact numbers:
6. Are personnel needed?

C 1. Yes. How Many?
i
r 2. No
7. List tasks/functions to be performed by requested personnel:
8. Are specialized/trained personnel required?

C 1. Yes. Identify:

Page No.00584
r 2. No
Is on-site security required for the:
9. Physical / Facility?
r 1. Yes
r 2. No
10. Personnel
r 1. Yes
r 2 . No
Weather Considerations:
11. Cooling required?

C 1. Yes
P 2. No
12. Heating required?

r 1. Yes
r 2. No
13. Cots or mattresses?

r 1. Yes
r 2. No
14. If yes, how many?
15. If yes, for general population?

r 1. Yes
r 2. No
16. If yes, for special needs (frail, obese, elderly)?
17. Can mattresses on the floor be used as a substitute for cots?

r 1. Yes
r 2. No
18. Who is responsible for the cots (pick-up and return): name, address, office # and cell

Page No.00585
19. Bedding (i.e. blankets)?
C 1. Yes. How Many?
r 2 . No
20. Cooking facility/feeding space required ?

r 1. Yes
r 2. No
21. Special Diets?

C 1. Yes. Please Identify (Kosher, Halal, Vegetarian, Allergies, Other):
r 2. No
22. Medications required?

C 1. Yes. Please identify:
i
i
j____________ ____________ _
r 2. No
(refer to medical supplies request form)
23. Are first aid stations required?

r 1. Yes
r 2. No
24. Additional Notes:
25. Is this a temporary animal shelter (teas) or a pet friendly shelter (pfs)?
r 1. Yes
r 2. No
26. Animal cages: indicate type/size and # of cages:

Page No.00586
27. Animal Feed: specify type of food (dog, cat, etc) and quantity:
Pet-friendly Evacuation Sheltering: allows humans and their companion animals to co-locate in the same room, facility, or campus.
This allows for the owners of companion animals to provide for the care and needs of their animals which reduces the need for
volunteers and other resources. Pet-friendly evacuation sheltering may include the use of commercial facilities, such as pet-friendly
motels/hotels.
Temporary Emergency Animal Shelters: This type of shelter provides care and housing to animals that can not be housed in the
same sheltering facilities as their owners. This may also include companion animals recovered or evacuated from impacted areas
for their own safety and whose owners may not have been identified. Shelters may be managed or staffed by local municipalities,
by approved Non-Governmental Organizations, by the Humane Society, or by the SPCA.
professionals.

Page No.00587
Request for Potable Drinking Water (for each site)
OPS 3-2 ______________________
1. Geographic area:
(Street Address, City/Village/Town and County)
2. Name of the impacted public water system:
Population Affected
3. Current Total:
4. Potential Total:
5. Event Situation
JT 1. Source water involved
I” 2. Finished water involved
f 3. Contamination event
I” 4. Loss of pressure in distribution system
I” 5. Loss of power
P 6. Infrastructure failure
r 7. Other:
6. Has the AHS been notified?

r 1. Yes
r 2. No
7. Equipment / Material Needed

I” 1. Quantity of pumps. Describe size/type:
P 2. Quantity of pipes. Describe size/type:

Page No.00588
I” 3. D.E. filters. Quantity:
P 4. Generator (submit generator request form for size/type). Quantity:
P 5. 5,500 tanker quantity:
P 6. 500 gallon water buffalo quantity:
P 7. Bottled water quantity:
P 8. Other (w/quantity)
8. Estimated Length of Time Water Will Be Needed:
Receiving Facility Information:
9. Required: Delivery Address Point
10. Point of Contact Name / phone number:
11. Available Interior Space by square feet:
12. Is unloading equipment available?

r 1. Yes
r 2. No
13. Is refrigerated storage available?

r 1. Yes
r 2. No
14. Is onsite security available at the facility?

r 1. Yes
C 2. No
15. Security Personnel available?

r 1. Yes
r 2. No

Page No.00589
16. Delivery Notes (Transportation required, loading / unloading / lift gates / loading docks / forklift / route obstructions):
i
i
ii
1. Distribution containers are the responsibility of the requesting entity.
professionals.

Page No.00590
Request for Food Assistance
OPS 3-3 __________ ___________ _
2. Number of sites to be served:
3. Number of Meals to be served:
4. Number of days meals needed to be served:
5. Location(s) of Meals served:
6. Shelter Capacity / Occupancy:
7. Operational Period Dates:
FOOD: (States Assets Limited Availability)
Bulk Food: (To be cooked / prepared at Shelter)

i ^ _ ____ _ ............... _ ........................... . _ _ j
Bulk Food / Ready to Serve: (Prepared meal that may require heating prior to serving)

I ...".... .................. ' ... ................. ............................' ......... !
10. Special Needs (explain):

Page No.00591
i
14. Other Needs:
FOOD: (Contracted Assets - Subject To Availability)
Meals-Ready-to-Eat (MRE)

F .... ' ' ~ _ _ _ _ _ ~ "
i___ _______ _____________ _ ____ _____ ____ _ __

I ~ ” ” ....... .... ~
i
i
i
i
19. Formula (specify liquid concentrate, powder, or ready-to-serve) Describe:

Page No.00592
20. Quantity of infants (not meals) Served Per Meal, daily:
r 1 ~ - ........... .~~..~..... ... ~.......... i
NON-FOOD ITEMS:
Paper Plates:

I__________________________ ,____________ _________ ______________________________________ I
Plastic Flatware
i”z z z ’ zzzrzzzzzz. ..zzz v_ z z /zj

Plastic Cups
Napkins
Plastic Bowls
Trash Bags
Paper Towels

i ’
j

Page No.00593
Waterless Hand Sanitizer
29. Other:
31. Preparation / Storage capabilities at Feeding Site:
professionals.
3. It is requestor's responsibility to notify POC of resource status, (arrival time, idle time, time used, demobilization time before the
actual demobilization, and time released.)

Page No.00594
Request for Fuel Assistance
OPS 3-5
1. BRIEF Description of Problem Encountered
2. Purpose for use of Fuel Requested (what you are refueling):
3. Type of Fuel(s) needed (check all that apply with amounts estimated, in GALLONS):
I” 1. Gasoline
t ;
( i
P 2. Diesel
I” 3. Kerosene
‘ ..... .... ...... ."..... ~ "" " .... .“ ................ " ‘ " ........... ' ;
I” 4. Autogas (LPG) (60% Propane 40% Butane)
P 5. Methanol
P ~ ........." ............. "" .. .......... .. ~
r 6. E85 (85% Ethanol)

| I
I” 7. Butanol
j ' ............... ............ ' ' ........ ..................... "'' " ' .
P 8. Gasohol (10% Ethanol 90% Gasoline)
V 9. AvGas (Aviation Gasoline)
P 10. Liquid Compressed Gas (CNG)
r 11. Liquid Hydrogen Gas (LHG)

; * I
P 12. Liquid Propane Gas (LPG)

.. .. ....... .. ............. .
- - ........." . ..................................... ....................................... ..................................... ‘ ............ ;
P 13. Liquid Natural Gas (LNG)
P 14. Nitrogen, in POUNDS

Page No.00595
I” 15. Acetylene, in POUNDS
V 16. Vegetable Oil
V 17. AvGas (Aviation Gasoline) JP-4
I” 18. AvGas (Aviation Gasoline) JP-5
I” 19. AvGas (Aviation Gasoline) JP-8
P 20. 2-Stroke Pre-Mix (fuel & oil)
F 21. Other
4. If 2-Stroke Pre-Mix, what is the Ratio (O il: Fuel - i.e. 20:1)?
5. Is fuel needed for:

F 1. Delivery to remote sites within Disaster
F 2. For fixed site locations for Vehicles to travel to
F 3. Other Location
[___ ___________________ . ___ _ _ ._ _________ _____ .
6. If other, is it a fixed site?

C 1. Yes. Location:
C 2. No
7. Are Tankers, Containers, Fixed Storage, or All needed for storage?

V Hankers:
j
P 2. Fixed Storage:
r 3. All:
8. What size of storage do you need for the above Tankers/Containers (in GALLONS)?
9. Address / Location of Storage Tanks:

Page No.00596
"1
10. Special Hauling/Fire Suppression Requirements: (i.e. Special Licenses, Permits, ID Placards, if fuel moved is owned
by others):
professionals.

Page No.00597
Request for Sanitary and Hygiene
OPS 3-6
1. Date/Time Asset Requested:
□zzzzn
2. Desired Asset Arrival Date/Time:
Affected Population
3. Potential Total:
[IZIIZZII i
4. Current Total:
5. Male (adult):
6. Female (adult):
{ 1
i_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
7. Boys:
i — — - ’ ' "
L__________________
8. Girls:
9. Infants:
10. Asset Location:
11. Geographic Size:
12. Threat / Conditions / Symptoms:
13. Skill Set / Expertise Needed:

Page No.00598
14. Total Personnel Needed:
15. Estimated length of time personnel needed:
16. Do you have waste removal capabilities?

r 1. Yes
r 2 . No
17. Waste Removal / Pick-Up Schedule
18. Are Local Assets Available:

r 1. Yes
C 2. No
19. Public Sector Assets:
20. Private Sector Assets:
21. Items Requested and Quantity:

I” 1. Port-a-Potty
I” 2. Hand Sanitizer
|
I” 3. Hand Washing Stations
V 4. Garbage Collection
I” 5. Foot Washing Station
1“ 6. Eye Wash Station
I” 7. Shower Systems
l~ 8. Garbage Disposal
P 9. Other

Page No.00599
P 10. Other
f” 11. Other
I..... ....
I” 12. Other
Receiving Facility Information
22. Is unloading equipment available?

r 1. Yes
C 2. No
23. Delivery Address Point information (include point of contact phone information):
i
i
i
24. Delivery Notes (Transportation required, loading/loading/forklift/route obstructions):
professionals.

Page No.00600
Request Fire Assistance (RFA)
OPS 4-1
This form must be completed for investigation and inspection calls for assistance received by the POC or directly by the Fire Rescue
Officer.
Copies of this form must be included on all inspection / investigation reports and saved to the "request for assistance" file on the
shared drive.
1.A B D LA N Ticket ID
2. In itial C a ll In fo rm a tio n :
Date Call Taken (DD-Mmm-YYYY): Time Call Taken (hhmm):
Name of POC Duty Officer: Name of on-call Fire Rescue Officer:
John Evans _^j Don Rosland _^J
3. A u th o rity H a v in g J u r is d ic t io n
Name of AHJ:
AHJ contact name and number:
Location of Incident:
Lead Fire Dept: RCMP File (if known):
Incident attended by AHJ?
r Yesr no
If NOT attended by AHJ, give reason why:
4. Nature of Call (Check all that apply)
Code Information r Large Loss - residential (over $10 million)

I- Commercial I Industrial I- Structure Fire
F Fire Code Information F Vehicle Fire
F Fire Code Inspection F Wild Land Fire
l- Injuries (minor)
F Large Loss - other (over $10 million)
If injured, the number of injured parties:

Page No.00601
f~ Assembly Occupancy (school, hall, etc.) I- 16. HIRF (3 or more occupied structures)
I- Drug Lab / Grow Op I- 17. Hospital or Health Facility
!“ Explosion [” 18. Injuries (severe)
V Fatal Fire !“ 19. Suspected Arson
T Group Home / Seniors Home P 20 Wildfire / Urban Interfaces
Number of severe injuries or fatalities:
If any o f the red-titled boxed are checked, an im m ediate phone call to the on-call
FRO is required.
Has FRO been notified?
r Yes r No
5. D etails o f In c id e n t
Date oflncident (DD-Mmm-YYYY): Time of the Incident (hhmm):
Is the fire out?

C Yes C No
Is the site secured? If "yes" then how? (fence, guard, etc.)

r Yes C No
Was the dwelling occupied? Number o f occupants

C Yes C No C U n k n o w n
A l l all occupants accounted for?
Name and contact number o f structure owner:
Is jurisdiction accredited in fire? Degree of Damage:
C Yes C No Minor
Is the fire on First Nations Land?

If yes, has First Nations FRO been notified?

r Yes r No
Brief Description of incident:
6. Assistance Required
I- Notification Only I- Investigative Advice
Page No.00602
n On-site Investigative Assistance P Investigation (non-accredited)
V Operational Assistance F Resource Query
(if yes, notify POC Manager) F Other
I f "other" please describe
Notification priority (do you require immediate call-back from the OFC
officer?)
P Immediate I” 8-24 hours call back I” Business Hours

Page No.00603
Request For Law Enforcement / Security Assistance
OPS 4-2
2. Is this emergency or routine?
3. What Type of Law Enforcement / Security is needed (fill in quantity needed)?

I” 1. Site Security
I” 2. Traffic Control
F 3. Crowd Control
V 4. VIP Security
j ~
r 5. Neighbourhood Security
I” 6. Street Patrol
V 7. Vehicle Escort Security

r
[ _
I” 8. Base Camp Security
F 9. Shelter Security
j " ..... ............. _ ....
F 10. Courts Security
I” 11. Investigation (Crime Scene)

j
I” 12. Local Distribution Site Security
F 13. Command Post Security
5. Exact Location and the population security is needed for:

Page No.00604
6. On-scene Commander Point of Contact:
7. Types of Vehicles needed (specify 4x4, capacity, etc.):
8. Estimated duration of Task:
9. Describe arrangements for lodging and meals, if any:
professionals.

Page No.00605
Search and Rescue (SAR)
O P S 4-3
All fields on this form are mandatory. "Not known at this time” should be entered if information for any field cannot be provided at the
time the form is created
1. A B D L A N T ic k e t ID
r
N o te : T ic k e t ID is a s s ig n e d a u to m a tic a lly w h e n th e tic k e t is sa v e d . P le a s e c o p y he re.
2. S A R In form ation :
Deployment Type:
(please specify)
Deployment Start Date (DD-Mmm-YYYY): Deployment Start Time (hhmm):
Deployment End Date (DD-Mmm-YYYY): Deployment End Time (hhmm):
N o te : E n d D a te a n d E n d T im e a re m a n d a to ry fie ld s u p o n in itia l fo rm c o m p le tio n , w ith th e

Search",
e x c e p tio n o f th e D e p lo y m e n t T ype "O p e ra tio n a l w h e re th e E n d D a te a n d E n d
T im e w ill b e p ro v id e d on c o m p le tio n o f th e search.
Contact First Name Contact Surname
Contact Phone Number
Name of SAR Organization Location of Deployment

(please specify) J (please specify)
Number of Members Participating
Notes

Page No.00606
Request for Transportation Assistance (Staff and/or Cargo)
OPS 4-4
1. Brief Description of Problem Encountered
2. Specify what needs to transported

r 1. Staff
P 2. Cargo
3. Specify quantity of what needs to be transported:
4. Specify type of transportation requested:

P 1. Helicopter
r” 2. Airplane
r 3. Car
P 4. Bus
r 5. Rail
P 6. Truck
P 7. Truck w/Trailer
P 8. Trailer
P 9. Boat
Staff:
5. Who is being transported?
6. Does Personnel need to be escorted?

P 1. Yes
r 2. No
7. Is Security of Personnel needed?

C 1. Yes
C 2. No
8. If yes to either for what purpose: (Investigation, Security, etc.)?

Page No.00607
9. Number of personnel to be transported:
10. Pick-Up Location:
11. Drop-Off Location:
12. Is Transportation from scene needed?

C 1. Yes. Define:
r 2. No
13. Will personnel be bringing baggage and/or equipment and/or animals?

r 1. Yes. Please specify:
l
l
r 2. No
Cargo:
14. What is being transported?
15. Is Security of Cargo needed?

r 1. Yes
r 2. No
16. Is Escort of Cargo needed?

r 1. Yes
r 2. No
17. If yes to either for what purpose: (Investigation, Security, Clean-up, etc.)
18. Pick-Up Location:
19. Drop-Off Location:

Page No.00608
20. Estimated Weight of Cargo (in pounds):
21. Type, Length, and/or Weight of Trailer:
22. Is special equipment needed for securing cargo?: (i.e. need to be palletized or not)
C 1. Yes. Please Specify:
I ~~ ~~ .. ...... ...... .... ......
f
f
r 2. No
23. Is special equipment needed for loading and off-loading (forklift, loading ramps, pallet jack, handtrucks)?
C 1. Yes. Please specify needed equipment:
ii
t
r 2 . No
24. Is Transportation from scene needed?

C 1. Yes. When is the transportation needed:
f ..... ..... ........................... . ........................... . .... ................................
! _ _____ _ _ _ _ _ _ _ ^
r 2 . No
25. Other Special Requirements: (hitch type, special driving permits, ID Placards, etc.)
NOTE: if requesting aviation support to transport, ensure the aviation support form is filled out in conjunction.
professionals.

Page No.00609
Request for (IMT) Incident Management Team / Logistics / EOC / ECC Support
OPS 4-6
1. Briefly explain the assignment or type of support requested from the IMT:
2. Brief Description of Geographic / Operational Incident Area (for GIS purposes):
3. Location / Address where IMT is to report:

r
4. Name and Number of contact when IMT arrives on-scene:
5. IMT Request to Staff (please choose one)

C 1. Incident Command Post (ICP)
C 2. Emergency Operations Centre (EOC/ECC)
6. Is the ICP (choose one):

C 1. Fixed Site
r 2. Mobile
7. Known political considerations:
8. Expected duration of deployment (choose one):

r 1. Less than 1 week
P 2 . 1 - 2 weeks
C 3. More than 2 weeks
9. Is lodging available nearby?

C 1. Yes. Name and address of the hotel / motel:
r 2. No
Page No.00610
C 3. Unknown
10. Length of Operational Periods (choose one)

P 1 ,8 hours
C 2 .12 hours
r 3. 24 hours
r 4. Other
11. Is fuel available to the affected area?

r 1. Yes.
C 2. No
12. If yes, identify type:

r 1. Gasoline
C 2. Diesel
13. Is cell service working in area?

C 1. Yes. Identify cell service provider(s):
r 2. No
14. Is internet service working in the area?

C 1. Yes. Identify internet provider:
r 2. No
15. Access to a medium or high volume printer/copier available?

r 1. Yes
r 2. No
C 3. Unknown
16. Is there power?

r 1. Yes
r 2 . No
17. Air Operations underway or anticipated?

r 1. Yes
r 2. No
P 3. Unknown
18. Is someone assigned to manage / track incident related finances?

P 1. Yes. Who?
r 2. No.
Page No.00611
professionals.

Page No.00612
Request for RASS (Rapid Assessment Structural Safety) Team s
OPS 4-9
1. Clear description of current conditions (environmental and known hazards):
2. Tasks/function to be performed:
3. Structures impacted:
4. Structure types:
5. Locations (include topography):
6. Staging area/briefing location:
7. Will fuel be available?

r 1. Yes
r 2. No
8. Will transportation be available?

C 1. Yes
r 2. No
Page No.00613
9. Are maps provided (folded or GIS)?
r 1. Yes
r . No
2
10. Specialty Items Needed (quantity):

P 1. Camera
" ' “ " ‘ ..... ..... ““
P 2. Laptop
P 3. Tape Measure
ri
P 4. Spray Paint
P 5. PPE
j ~ * "* " ~~
P 6. Levels
P 7. Other (Identify)
11. Is accommodation being provided?

r 1. Yes
C 2. No
professionals.

Page No.00614
Request for D M O R T (Disaster Mortuary Operational Response Team )
OPS 4-10
1. Type of Incident:
2. Approximate number of fatalities:
3. Known # of deaths (open*):
4. Unknown # of deaths (closed*):
5. Name of the Coroner/Medical Examiner's Office requesting DMORT (name and number):
6. Point of Contact for DMORT services (name and number) if different from above:
7. Exact location of morgue/s for this event:
8. Description of victims on-scene (environmental and known hazards):
9. Description of conditions on-scene (environmental and known hazards):
10. Describe assets being requested (i.e. on-scene or at the morgue, forensic pathology, recovering remains, ante or
postmortem collection, personal effects processing, safety officers and specialists, etc as listed on dmort.com):
11. Address of Staging Area or where DMORT is to report:

Page No.00615
Examples:
*Open - the # of passengers on an airplane based on their passenger manifest
"Closed - a building collapse during normal work hours
professionals.

Page No.00616
Request For Resources or Assistance
OPS 6-1
1. Event Name
2. Date/Time Request Needed
3. Is this request:
C 1. Life Safety
r 2. Priority
C 3. Routine
4. Person submitting request: (name and number)
5. Requesting individual (if different from above):
6. Requesting Entity Agency
7. Phone Number(s) they can be reached at
8. Local Authority Requesting Resource
L___ _______________________ ___
9. BRIEF description of problem encountered:
10. Resource Requested
11. Quantity of Resource requested:
12. Current Resources committed to identified tasks / functions

Page No.00617
13. Have all local capabilities associated with this resource been exhausted?
r 1. Yes
r 2. No
14. What sources/vendors have been contacted? Please list
15. Potential Substitute (if specific resource not available)
16. Personnel Required to Operate, Support, and Maintain: (Including Shift Rotations) (include quantity and kind)
17. Support Equipment needed (i.e. fuel, water, delivery schedules, etc.)
18. Approximate length of time resource is needed, (hours, days, weeks, etc) Including shift rotations
Delivery Information:
19. Delivery Point:

; ..... * ' ....... " .......................... .................................... "........“ ‘ ‘ ....................j
20. Delivery Contact Name:
21. Delivery Phone:
22. Delivery Notes: (Transportation required, loading / unloading notes, type of hitch):

Page No.00618
1. Advise Requestor of receipt of this request and provide the DisasterLAN Ticket Number.
2. This request must be submitted with each specific resource form.

Page No.00619
Linear Property Assessment Complaint Form - Part 1
Municipal Government (Section 491(1) of the Municipal Government Act)
W a Board (MGB) Any miiirr Util U in li r ilcail mill In a hearing fafare Ilx Bnnl ivut-i Ik In Ihr farmprrscrilTil hy ihc Krj>uUli.m
ami mnl It Jllnl <*llh Ibe ailJKia-tr'nl.r its faUam: •) fira raiT|i|<um III“Mil tn«wi«ir»nl furlimnirpnnirrty,
0.-1 b u rthaniht «iaK ..nihf a ^ ^ w n - iic r. PLEASE E-MAIL COMPLETED COMPLAINT FORM TO m nbm ail® gov.ab.ca: FEE PAYMENTS MAY BE MADE BY MAIL C
Contact Name: Adilute: Phone Number: E-Mail:
Assesses Name:
Complainant Name or
Agent/Organization Name:
(if different from above):
Discussed Complaint w ith DLA? □ Yes ENo
Pni-rty PruprrtyTyye AssmMun AJ. \TA III Mollit far Kt.)iinlnl Avsrssttl Value Tik- htcI InfammllmilMOA >. 49||.l)fa}l Wily InTnmBillnn is Imnnrrl ('.iiik I Int.irnnlliiiHMCA ». Sunrauy "f Issues. P«llion & Rrwmtli
i r u in ('vRlIlliiiM tMSTOHl IMCA *.J»jnH4lt iMliA s. 4'>ll.fatHh *n»K O> (MCA fcA9|(3Hnl*(h|J
IM C U H H Ill Ptnur nil In "0“ If MiUlrrOir prreMspts.Tlfad hy the Mminer'- liuiJHmcs u im.arrel Identity Ihc H-plain in t-hal ir']r, 1ihr Whal is Ihc cimril ■nfumutnin t data In fa used in Ik llatuij ilj'jiJ h« ihc iixisnit utfatnulira/ dal*
C'liliyd-lrU il»rt rr'1 ItlaK It ndfauulum i J-I- uacd in lire linear prifcri) as-e-s^nemcakulMum j r w n . and
LPAlJ-in MWKnxnt LjUuljlitm pnqlimeyi issue* and itx rcauav- l.i s*i|y»»t
--------------------------------- i--------------------
------------------1----------
Tula! Filin g r~ - f / " ir \ Dolt: Payment
Fee: 4>OJU.UU (lill-M M -Y Y l ________________________________ Method:
Total Properties under

complaint: 0
Authtnicd Signature it (.'itrplainailVAgtM liy <’irnpUinari
This information is being collected for the purposes of setting up each hnear property complaint for a hearing in accordance with s. 491(1) of the Municipal Government A c t The information collected wHI be managed in compliance with the Freedom of information and Protection of Privacy Act and in
accordance with the practices and procedures of the Municipal Government Board. Questions about the collection and use of this information can be directed Alberta Municipal Affairs, Municipal Government Board at (780) 427-4864.
Page t oM

Page No.00620
[ p i Municipal Government Linear Property Assessment Complaint Form
f t Board (MGB) (Section 491(1) of the Municipal Government Act)
Part 2
Important Information
1 If this complaint is being filed on behalf of the assessed owner or taxpayer by an agent, the prescribed agent authorization form must be completed by the owner or taxpayer
of the property and must be submitted with this complaint form. The Authorization form is available on the Municipal Government Board (MGB) W ebsite, under Forms and Reports
at http://www.munic:ipalaffairs.alberta.ca/abc_mgb_forms.cfm
2 The details and reasons for a complaint must be provided on the complaint form and include:
a) what information shown on an assessment notice is incorrect. This information must have been used in the calculation process prescribed by the Guidelines, and must relate to an
applicable section and / or sub-section of the 2009 Minister’s Guidelines for Linear Property Assessment.
b) in what respect that information is incorrect
c) what the correct information is, and the data source from which this information is derived;
d) the specific issues related to the incorrect information that are to be decided by the MGB, including the grounds in support of these issues;
e) the requested assessed value; and
f ) whether the complainant and Respondent have discussed matter for complaint.
3 The complainant must also include a copy of the original assessment notice with this complaint form .
4 Your completed complaint form and any supporting attachments, the agent authorization form, and the prescribed filing fee must be submitted to the MGB, prior to the deadline indicated
on the assessment notice. Complaints with an incomplete complaint form, complaints submitted after the filing deadline, or complaints without the required filing fee, are invalid and the
MGB must dismiss the complaint. PLEASE E-MAIL COMPLETED COMPLAINT FORM TO mgbmai!@gov.ab.ca; FEE PAYMENTS MAY BE MADE BY MAIL OR IN PERSON TO
MGB OFFICES IN EDMONTON OR CALGARY.
5 The MGB must not hear any matter in support of an issue that is not identified on the complaint form.
This information is being collected for the purposes of setting up each linear property complaint fo ra hearing in accordance with s. 491(1) o f the Municipal Government Act. The information
collected will be managed in compliance with the Freedom o f Information and Protection o f Privacy Act and in accordance with the practices and procedures o f the Municipal Government
Board. Questions about the collection and use o f this information can be directed Alberta Municipal Affairs, Municipal Government Board at (780) 427-4864.

Page No.00621
Category of Complaint Code Category of Complaint Description
EA Exempt of Assessment
LA Legal Argument
LD Legal Description / Location
Li Legislative Interpretation
NB Property Not Built
MA Municipal Allocation
NA Not Assessable
OM Omission
OW Ownership
AA Schedule A - ACC
AT Schedule A - 1C
AC Schedule A - Cost Factor
AB Schedule A - Base Cost
BA Schedule B - AYM Factor
CC Schedule C - Code
CF Schedule C - Factor
' DC Schedule D - Code
DF Schedule D - Factor
OT Other

Page No.00622
Property Type Code Property Type Description
ERG Electrical Power Gen
Matter for Complaint Code Matter for Complaint Description

DS Description of any linear property
AD Name and address of an assessed person
AS An Assessment
IT Type of improvement
SS School Support
AP Linear Property is assessable
EX Linear Property exempt from taxation under Part 10

Page No.00623
Linear Property Assessment Complaint Form * Part 1
Municipal Government (Section 491(1) of the Municipal Government Act)
&A Board (MGB) r l h i l h b b i .1r-.il mllrln • .
<cr.lt.1 wUhlhr •>
f brfnn ih. Mnanl hi M f-rm pm .rtbtil Ih Ihr
■ranri* f-f lh»»r |.n.|>rm,
PLEASE E-MAIL COMPLETED COMPLAINT FORM TO mqbmajHagov.iib.ea: FEE PAYMENTS MAY BE MADE BY MAIL C
Contact Name: Add™. Phone Number: E-Mail:
Assesses Name:
Complainant Name or
Agent/Organimtron Name:
(if different from above):
Discuased Complaint w ith DLA? G Ves G No
V w i'lin A l VIA in M.ill.r (..f !.«»■ C|.|. J-.H Hr.|nrkln1 A h ra n l Vulur reri IntormiEMilMtiA ». U ln Infnrmiliiflli llwiirrfI ('..m il rnfuninlk.nl MCA w.
MOA 4'JlOndlJ InJiuir »hil m|.inn*U*n/djuuwJ inrhc w > (MCA «. 4V14AKl.1l 4 »tf.tKt|> MCA * -WK2M)
(M C.W J OUn l'lm ^ n U lii“l)" irU aiir. ss.f»r«.nhed by Ihr Minivlci .>Ckintrlmc* i IApliih in «1»l ! Ibe Whm i»lbe ( . t o ! mlntnaJi.n •lj.ill- frj;.ud tic Eh.
o in Uw Mmwr'-CiinIclHKmi hfcuhihc mlivnull.n I d.u uirj in Ihr upl iin iJw jpecilk I
I.IW -
)IU
T o ta l r ilin g Payment
$ 0.00 Method:
Total Pioperties under

complaint:
AliIihuc J Nipuiurc w OfnffUMnVAfeM
This information is being collected for the purposes of setting up each linear property complaint lo r a hearing in accordance with s 491(1) o f the Municipal Government Act. The information collected ivrff he managed m compliance with the Freedom of Information and Protection of Privacy Act and in
...at. ,K„ a n * ---- r u r r.t ,h u --------------- . o r r , . Qn-*rr4 -A — •*.„ o~V r— * a A b - b E .IJKuH, M -c k -in ./ M l,,"- ---- -------« ~ o ~ J a . /70/1I 4 0 7 .4 0 0 4
Pag® 1 of 1

Page No.00624
|-;v Municipal Government Linear Property Assessment Complaint Form
ma Board (MGB) (Section 491(1) of the Municipal Government Act)
Part 2
Important Information
1 If this complaint is being filed on behalf of the assessed owner or taxpayer by an agent, the prescribed agent authorization form must be completed by the owner or taxpayer
of the property and must be submitted with this complaint form. The Authorization form is available on the Municipal Government Board (MGB) W ebsite, under Forms and Reports
at http://www.municipalaffairs.alberta.ca/abc_mgb_forms.cfm
2 The details and reasons for a complaint must be provided on the complaint form and include:
a) what information shown on an assessment notice is incorrect. This information must have been used in the calculation process prescribed by the Guidelines, and must relate to an
applicable section and / or sub-section of the 2009 Minister's Guidelines for Linear Property Assessment.
b) in what respect that information is incorrect
c) what the correct information is, and the data source from which this information is derived;
d) the specific issues related to the incorrect information that are to be decided by the MGB, including the grounds in support of these issues;
e) the requested assessed value; and
f ) whether the Complainant and Respondent have discussed matter for complaint.
3 The complainant must also include a copy of the original assessment notice with this complaint form .
4 Your completed complaint form and any supporting attachments, the agent authorization form, and the prescribed filing fee must be submitted to the MGB, prior to the deadline indicated
on the assessment notice. Complaints with an incomplete complaint form, complaints submitted after the filing deadline, or complaints without the required filing fee, are invalid and the
MGB must dismiss the complaint. PLEASE E-MAIL COMPLETED COMPLAINT FORM TO mgbmail@ gov.ab.ca; FEE PAYMENTS MAY BE MADE BY MAIL OR IN PERSON TO MGB
OFFICES IN EDMONTON OR CALGARY.
5 The MGB must not hear any matter in support of an issue that is not identified on the complaint form.
This information is being collected for the purposes o f setting up each linear property complaint for a hearing in accordance with s. 491(1) of the Municipal Government Act. The information
collected will be managed in compliance with the Freedom o f Information and Protection o f Privacy Act and in accordance with the practices and procedures o f the Municipal Government
Board. Questions about the collection and use o f this information can be directed Alberta Municipal Affairs, Municipal Government Board at (780) 427-4864.

Page No.00625
Category of Complaint Code Category of Complaint Description
AB Abandoned
ER Error in AEUB Record
DP Depreciation
D Discontinued
EA Exempt of Assessment
MS GDP No. of Meter Sets
SL GDP No. of Service Lines
LA Legal Argument
LD Legal Description / Location
Li Legislative Interpretation
PD Pipe Diameter
PL Pipe Length
PM Pipe Material
PP Pipe Pressure
PS Pipe Status
NB Property Not Built
WD Wei! Depth
WS Well Status
MA Municipal Allocation
NA Not Assessable
OM Omission
OW Ownership
AA Schedule A - ACC
AQ Schedule A - Qty
AT Schedule A - 1C
AC Schedule A - Cost Factor
AB Schedule A - Base Cost
BA Schedule B - AYM Factor
CC Schedule C - Code
CF Schedule C - Factor
DC Schedule D - Code
DF Schedule D - Factor
OT Other

Page No.00626
Property Type Code Property Type Description
PL Pipeline
WL Well
CBL Cable TV
TEL T elecommunication
GDP Gas Distribution
ELE Electric Power Systems
Matter for Complaint Code Matter for Complaint Description

DS Description of any linear property
AD Name and address of an assessed person
AS An Assessment
IT Type of improvement
SS School Support
AP Linear Property is assessable
EX Linear Property exempt from taxation under Part

Page No.00627
Municipal Government Municipal Government Board
10155-102 Street
Edmonton AB T5J 4L4
& A Board (MGB) Tel 780.427.4864 - F a x 780.427.0986
Withdrawal Form
Linear Property Assessment Complaints
Name of Complainant (Assessee):
Assessee MA ID:
Authorized Representative (if any):
Assessment Year: or Tax Year:
Please list the complaints you wish to withdraw OR attach a spreadsheet with the same information.
Municipality ID Property ID Municipality ID Property ID

<TJ MA ID) (LPAU ID) (TJ MA ID) (LPAU ID)
Signature of Complainant OR Person authorized Date

to act on b e h a lf o f C om plainant
# of Attachments:
Note: a complaint filed with the Municipal Government Board (MGB) remains outstanding until a
recommendation or withdrawal for this complaint has been received by the MGB. Should you receive an
amended notice that involves a filed complaint, the MGB will NOT know whether you agree with the amendment
or not. If you are satisfied with the amendment, please withdraw your complaint with the MGB.
This information is being collected for the purposes of setting up each complaint for a hearing in accordance with Section 491(2) of the
Municipal Government Act and will be managed in compliance with the Freedom of Information and Protection of Privacy Act. Questions
Alberta MUniei-pa'I A ffa irs Information! R©qu6Sfr20t5-R-0088
Place, Edmonton, Albeda T5J 4L4, (780)427-4864 (Outside o f Edmonton call 310-0000 to be connected toll free). Page No.00628
- Municipal Government Appeal Received MGB Use Only
Notice of
& A Board (MGB)
Subdivision Appeal
CONTACTS SEND TO : Municipat Government Board
15!tl Floor Commerce Place
Telephone: 780-427-4864 1 0 1 5 5 - 102 Street
Edmonton AB T5J 4L4
Web URL: http://www.mab.alberta.ca
Fax: 780-427-0986
Emait: mqbmail@aov.ab.ca
A notice for subdivision appeal under section 678 of the Municipal Government Act should contain the following information and must
be filed with the MGB office within 14 days after receipt of the written decision of the subdivision authority or deemed refusal by the
subdivision authority in accordance with section 681.
Part 1 - General Information - Please Print
PROPERTY UNDER APPEAL

Name of Municipality Subdivision Authority (if applicable) Subdivision Authority File Number
Does the land that is the subject of the appeal contain, or is it adjacent to, or near, any of the following? (Check ALL that apply)
□ Highwayf#................) CD Body of Water (Warrte, if n a m e d ......................................) CD Landfill CD Sewage Treatment Facility CD GreenArea
Legal Description Lot Block Rian A N D /O R Portion Section Township Range Meridian
A P P E L L A N T (e.g. L a n d o w n e r o r d e p a r tm e n t lo d g in g th e a p p e a l)
Name (Last) (First) Telephone Number (daytime)
Address (Street, PO Box, RR) (Suite, Apartment) (Town/City/Village) (Province) (Postal Code)
E-mail Address Fax Number
L A N D O W N E R IN FO R M A TIO N (if d ifferent from A ppellant)

A G E N T IN FO R M A TIO N A N D C E R T IF IC A TIO N (if A p pellan t is R epresented by an A gent)

Name of Organization
Contact Name (Last) (First) Telephone Number (daytime)
Address (Street, PO Box, RR) (Su/fe, Apartment) (Town/City/Village) (Province) (Postal Code)
1(We) hereby authorize to act on my (our) behalf on matters pertaining to this subdivision appeal
Signature of Ownerfs) Date Signature of Ownerfs) Date
Page 1 Alberta Municipal Affairs Information Request 2015-R-0088

Page No.00629
Part 2 - Decision of the Subdivision Authori
DECISION OF SUBDIVISION AUTHORITY

year month day
Date of Copy of Subdivision Authority □ YES □ NO
Decision Decision attached?
Part 3 - Reasons for Appeal
All subdivision appeals must contain the reasons for appeal, including the issues in the decision or the conditions imposed in the
approval that are the subject of the appeal.* (Attach extra page(s) if required)
EH Approval - What conditions of approval do you disagree with and why? OR
□ Refusal —Why do you think your subdivision application should be approved?
* See M u n ic ip a l G o v e rn m e n t A c t, section 678(4){b)
Part 4 - Pre-Hearing Meetings
It is recommended that you discuss your appeal with the Subdivision Authority, Alberta Transportation and Alberta
Environment and Parks (if applicable) prior to the appeal hearing.
Did you discuss your appeal with a representative from the Subdivision Authority? EHYES □ NO
Did you discuss your appeal with a representative from Alberta Transportation? EH YES □ NO
Did you discuss your appeal with any other agencies or departments? EHYES □ NO
If yes, please specify ......................................................................................................................................................
Signature of Appellant OR Date

Person Authorized to Act on Behalf of Appellant
This information is being collected for the purposes of setting up appeal hearings in accordance with Section 33(c) of the Freedom of Information and Protection of Privacy
Act. The contact information you provide may also be used to conduct follow-up surveys designed to measure satisfaction with the appeal process. Questions about the
collection of this information can be directed to Alberta Municipal Affairs, Municipal Government Board, 15th Floor, Commerce Place, Edmonton, Alberta T5J 4L4
780-427-4864. (Outside of Edmonton call 310-0000 to be connected toll free.)

Page No.00630
RETURN TO:
Municipal Government Municipal Government Board Notice of
Board (MGB) 151h Floor Commerce Place 1 0 1 5 5 -1 0 2 Street
Subdivision
Edmonton AB T5J 4L4
Telephone: 780-427-4864 Fax: 780-427-0986
Email: mgbmail@gov.ab.ca Appeal
As per section 678(1) of the Municipal Government Act (Act), the decision of a subdivision authority on an application for subdivision
approval may be appealed (a) by the applicant for the approval, (b) by a government department if the application is required by the
Subdivision and Development Regulation to be referred to that department, (c) by the council of the municipality in which the land to be
subdivided is located if the council, a designated officer of the municipality or the municipal planning commission of the municipality is
not the subdivision authority, or (d) by a school authority.
Part 1 - General Information - Please Print
A notice for subdivision appeal under section 678 of the Act should contain the following information and must be filed within 14 days
after receipt of the written decision of the subdivision authority or deemed refusal by the subdivision authority in accordance with
section 681.
□ Highway (#.................... ) 0 Water Body (Name .............................................. ) 0 Landfill 0 Sewage Treatment Facility O Green Area
Legal Description Lot Block Plan AND/OR Portion Section Township Range Meridian
APPELLANT (Landowner or department lodging the appeal)

LANDOWNER INFORMATION (if different from Appellant)

Address (Street, PO Box, RR) (Suite, Apartment) (Town/CityA/illage) (Province) (Postal Code)
AGENT INFORMATION AND CERTIFICATION (if Appellant is Represented by an Agent)

1(We) hereby authorize to act on my (our) behalf on matters pertaining to this subdivision appeal
Signature of Ownerfs) Date Signature of Owner(s) Date

Page No.00631
Part 2 - Decision of the Subdivision Authori

year month day
Part 3 - Reasons for Appeal
As per section 678(4) of the M u n ic ip a l G o v e rn m e n t A c t, all subdivision appeals must include the reasons for appeal, including the
issues in the decision or the conditions imposed in the approval that is the subject of the appeal. (Attach extra page(s) if required)
□ Approval - Which of the conditions of approval are under appeal and what are your reasons for disagreeing with those
conditions? OR
ED Refusal - Please give the reasons why you think your subdivision application should be approved?
Part 4 - Pre-Hearing Meetings
It is recommended that you discuss your appeal with the Subdivision Authority, Alberta Transportation, Alberta Sustainable
Resource Development, and Alberta Environment and Water (if applicable) prior to the appeal hearing.
Did you discuss your appeal with a representative from the Subdivision Authority? EDYES □ NO
Did you discuss your appeal with a representative from Alberta Transportation? EDYES □ NO
Did you discuss your appeal with any other agencies or departments? EHYES □ NO
If yes, please specify

Act. The contact information you provide may also be used to conduct follow-up surveys designed to m e a s u re satisfaction with the appeal process. Questions about the
collection of this information can be directed to Alberta Municipal Affairs. Municipal Government Board. fS” Floor. Commerce Place. Edmonton. Alberta T5J 4L4

Page No.00632
I 'Jg Municipal Government Subdivision
Board (MGB) Exhibit List
F ile # _______________________________________ Appellant
Hearing Date(s) __________________________________________
Panel Members
T'li Submitted Length Submission

Exhibit # Title/Author ,
by {in pages) Date
Page___ o f____
Page No.00633
Agenda No.: Date of Hearing: Time o f Hearing: Decision Model
P residing O ffic e r C o m pla in ant O rd e r to be D ra fte d B y
M em b er P ro p e rty D escription
M em b er R espondent ASSESSMENT UNDER COMPLAINT
Clerk R o ll No, DECISION
issues Legislation Arguments/Evidence Findings Reasons

Appellant
1.
Respondent
Appellant
2.
Respondent
Appellant
3.
Respondent
January 2015 -1 7 -
Issues Legislation
Arguments/Evidence Findings Reasons
Appellant
4.
Respondent
Appellant
5.
Respondent
6. Appellant
Respondent
7. Appellant

January 2015 18 ■
Agenda No.: Date of Hearing: Time of Hearing: I Decision Model
Presiding Officer: Roll No.: DECISION:
Member: Complainant: ASSESSMENT UNDER COMPLAINT:
Member:
Clerk: Respondent: Property Description:
Order to be drafted by:
Issues Legislation Appellant’s Argument Respondent’s Argument Findings Reasons
1.
2.
3.
Ja n u a ry 2015 -1 - Decision Model

M :\_ M G B \0 1 7 0 6 _ T r a in in g _ D e v \P 0 4 P ro v in c ia l T ra in in g P r o g r a m \ M a n u a ls - 2 0 1 4 - 2 0 1 5 \A d m in L a w 2 M a n u a l\R e s o u r c e m a te ria l\D e c is io n _ M o d e l_ 5 h e e t_ L E G A L _ N E W .d o c
Page No.00636
Issues Legislation Appellant’s Argument Respondent’s Argument Findings Reasons
4.
January 2015 -2- Decision Model

M:\_MGB\01706_Training_Dev\P04 Provincial Training Program\Manuais - 2014-2015\Admin Law 2 Manual\Resource material\Decision_Model_Sheet_LEGAL_NEW.doc
Page No.00637
Liberia Personal Expense Claim
(Charged to
Business Unit Prog Code Org Code Project Code
144A 10500 01
Name of Ministry Name of Claimant Vendor Number
Municipal Affairs
Have you changed your .— . .— . Mailing/Home Address
current mailing address? 1— 1 Yes 1— 1 No
If you are on direct deposit, has your banking i— i Yes r^-i No If yes, please complete a new Application for Direct
information changed since your last claim? 1— ' '— 1 Deposit and attach it to this claim.
Branch Title Work Phone
Municipal Government Board Board Member
Date Depart/Arrive Description of trip and other Acct Private Meals Lodging Other
(m m -dd-yyyy) Times expenses Code Car Km B L D Amount Expenses Expenses
A B C
Totals 3
Kilometre Claim Amount

Date Expenses not paid by claimant Rate Km
Private Car Km
Previous Kilometres .505
Total Kilometres to date

(April 1 - March 31) D
Totals 3
I certify that the whole of the expenditure was incurred on government

business and that amounts claimed have not previously been paid to me
or on my behalf, nor have they been charged to a government issued
credit card.
Total Claim (A + B + C + D) $
Signature of Claimant Date Less Advances
_Yes _X_ No $
Amount Payable by Claimant

$
_ Cheque __Cash
Approved Date
Amount Due Claimant 3 $
G 0690 (Rev. 2008/05) Page 1 of 2

Page No.00638
GUIDELINES FOR COMPLETION OF PERSONAL EXPENSE CLAIM
1. General
An expense claim will be approved for payment only if it is completed in accordance with the travel regulations. Employees
should refer to the regulations to ensure that all claims for allowances or expenses not supported by receipts are as specified in the
regulations.
It is the policy of the Government to pay personal and travel expenses necessarily incurred by employees in the performance of
their duties. Employees are neither asked to subsidize the cost of Government nor invited to indulge themselves at the public
expense.
Where per diem allowances stated in regulations are inadequate to cover expenses incurred, employees may claim reimbursement
for actual expenses but such expenses must be supported by receipts and be within the spirit and intent of the Government’s
policy stated above.
2. Information to be entered on the Expense Claim

The following is provided to assist in completing specific information areas of the expense claim:
DESCRIPTION OF TRIP AND OTHER EXPENSES - the description should include:

- purpose of the trip,
- points visited,
- description of any expenses.
CHARGE TO - the Account Code or appropriate Imagis code to which the expense is to be charged.
PRIVATE CAR KILOMETRES —this column provides for a daily accumulation of kilometres traveled on government
business in the claimant’s private automobile.
MEALS - the number of meals being claimed are to be entered under the B, L and D columns (Breakfast, Lunch and Dinner) and
the amount claimed entered in the amount column.
OTHER EXPENSES - this column includes the amount of any expense which cannot be classified as meals or lodging. Items
such as gasoline for government vehicles, telephone and postage and the per diem allowance for personal expenses are to be
recorded in this column with an appropriate description under the description column. When gas or oil is purchased for a
government vehicle a receipt must be kept for audit purposes.
EXPENSES NOT PAID BY CLAIMANT - the description and amount of any expenses not paid by the claimant such as items
pre-paid, charged directly to the department, or paid by another employee.
KILOMETRE CLAIM-
CLASS - the kilometre class claimed as specific in the travel regulations.
RATE - the rate in cents per kilometre that is being claimed for the class.
KILOMETRES - the total number of kilometres being claimed for the class.
AMOUNTS - the number of kilometres times the rate per kilometre.
TOTAL CLAIM - the sum of the total meals expense, total lodging expense, total other expense and the total kilometre claim.
LESS ADVANCES - the amounts of any advances, which are to be deducted from the total claim. The claimant should not enter
the transator numbers.
AMOUNT PAYABLE BY CLAIMANT - the amount due the government when the amount of the advance(s) is greater than
the total claim.
AMOUNT DUE CLAIMANT - if there are not any advances this amount is equal to the total claim. When one or more
advances are applied against the claim this amount is the difference between the total claim and the total of the advance(s).
G 0690 (Rev. 2008/05) Page 2 of 2

Page No.00639
. Municipal Government
& A Board (MGB)
Municipal Government Board
Code of Conduct Declaration
l a m a member of the Municipal Government Board (MGB).
1have read and understood the MGB C o d e o f C o n d u c t a n d E th ic s .
! undertake to comply to the best of my ability with the provisions of the MGB C ode o f
C o n d u c t a n d E th ic s and any subsequent amendments.
I understand that failure to comply with the MGB C o d e o f C o n d u c t a n d E th ic s may result in

disciplinary action including recommendation for suspension of my appointment.
Signed
Dated

Page No.00640
BUYER PROTECTION
BOARD
New Home Buyer Protection Board
Code of Conduct Declaration
I am a member of the New Home Buyer Protection Board (NHBPB).
I have read and I understand the NHBPB C o d e o f C o n d u c t a n d E th ic s .
I undertake to comply to the best of my ability with the provisions of the NHBPB C o d e of
C o n d u c t a n d E th ic s and any subsequent amendments.
I understand that failure to comply with the NHBPB C o d e o f C o n d u c t a n d E th ic s may result

in disciplinary action including recommendation for suspension of my appointment.
Name Signed
Witness Date

Page No.00641
A N N E X A T I O N A P P L I C A T I O N - C H E C K 1 ,1 S T
T h e f o llo w in g c h e c k li s t id e n tifie s t h e in f o r m a t io n r e q u ir e d w h e n s u b m it t in g a n e g o tia t io n r e p o r t / a n n e x a t io n

a p p lic a tio n to th e M u n ic ip a l G o v e r n m e n t B o a r d ( M G B ) .
A c tio n /R e q u ir e m e n t C o m p le t e d
1. A p p l i c a t i o n F e e ( C h e q u e p a y a b l e t o t h e G o v e r n m e n t o f A l b e r t a ) $ 3 0 0 f o r 1 st q u a r t e r ; $ 5 0
f o r e a c h a d d itio n a l q t r o r p r o tio n o f q t r .
Cheque amount $ Yes/No/NA
2. A n u p -to -d a te m ap s h o w in g th e lo c a t io n o f th e e x is tin g m u n ic ip a l b o u n d a r y and th e

p ro p o s e d m u n ic ip a l b o u n d a r y , w it h e a c h p a rc e l to b e a n n e x e d id e n tifie d b y le g a l la n d
d e s c r ip tio n .
Map showing existing boundary and proposed boundary Y e s /N o /N A
Legal land description of each parcel Y e s /N o /N A
3. E x c e r p t s f r o m a n y M u n i c i p a l D e v e lo p m e n t P la n o r o t h e r S t a t u t o r y P la n .
MDP Excerpts Y e s /N o /N A
ASP Excerpt Y e s /N o /N A
Other Excerpts (If any) Y e s /N o /N A
4. A d e s c r ip t io n o f t h e in te n d e d u s e s f o r t h e a n n e x a tio n a r e a in c lu d in g a g e n e r a l d e s c r ip tio n
o f how th e a re a can be s e r v ic e d w ith w a te r, s e w e r, s to rm sew er and o t h e r r e la te d
m u n i c i p a l s e r v ic e s .
Intended uses Y e s /N o /N A
Water Servicing Y e s /N o /N A
Sewer Servicing Y e s /N o /N A
Storm sewer Servicing Y e s /N o /N A
Other Servicing Y e s /N o /N A
5. T h e w r itte n c o n s e n t ( o r s ig n e d n e g o t i a t i o n r e p o r t ) o f t h e m u n i c i p a l i t y f r o m w h ic h th e
l a n d is t o b e a n n e x e d .
Written Consent of other Municipality Y e s /N o /N A
6. I f a n u n c o n t e s t e d a p p l i c a t i o n (s e e i t e m # 4 o n t h e p a g e 3 ) , t h e s ig n e d w r i t t e n c o n s e n t o f
e a c h l a n d o w n e r w h o s e l a n d is i n t e n d e d t o b e a n n e x e d , a n d a s t a t e m e n t t h a t t h e r e a r e n o
know n o b je c tio n s fro m th e g e n e ra l p u b lic ( a ls o in c lu d e th e f o llo w in g in fo r m a t io n
r e g a r d in g p u b lic c o n s u lta tio n i f s u c h c o n s u lta tio n o c c u r r e d ) .
Signed forms/letters from all landowners consenting to the annexation
and acknowledging the assessment and taxation conditions Y e s /N o /N A
Statement/Certificate that there are no known objections Y e s /N o /N A
Information regarding public consultation Y e s /N o /N A
7. I f n o t u n c o n t e s t e d ( i. e . n o s i g n e d c o n s e n t s f r o m t h e la n d o w n e r s ) , t h e r e s u lt s o f t h e p u b l ic
c o n s u lta tio n p ro c e s s , in c lu d in g id e n t if ic a t io n o f w h a t c o n c e r n s w e r e r a is e d a n d i f t h e y
w e r e r e s o lv e d , h o w a n d w i t h w h a t c o n d it io n s .
Public consultation process results Y e s /N o /N A
identification of public concerns Y e s /N o /N A
How concerns resolved Y e s /N o /N A
List of conditions required to resolve land owner/public concerns Y e s /N o /N A
(N o te : A p p l i c a t i o n s h o u l d p r o v i d e r a t i o n a l fo r4 lb 9 ilftM u n iiiP Ib A lff '( b InfOf T I ) ii>C)Requep^ 1Nj-o,R;° 682

8. C le a r id e n tific a tio n o f w h ic h b o u n d a ry ro a d s a re to be in c lu d e d o r e x c lu d e d in th e
a n n e x a t io n ( p le a s e e n s u r e m a p c le a r ly r e f le c t s t h is ) .
Map and written description of boundary roads included or excluded Y e s /N o /N A
9. U p t o d a t e c o p ie s o f l a n d t i t l e c e r t i f i c a t e s f o r e a c h p a r c e l p r o p o s e d t o b e i n c l u d e d i n t h e
a n n e x a t io n ( t h e c e r t if ic a t e m u s t h a v e b e e n is s u e d w i t h i n t h e la s t 6 m o n th s ) .
Land title certificates for all parcels (6 month) Y e s /N o /N A
10. A lis t o f th e n a m e s a n d m a ilin g a d d re s s e s o f e a c h la n d o w n e r ( w it h t h e ir c o r r e s p o n d in g

p a r c e l id e n tifie d ) and any o th e r p a r ty know n to have an in te r e s t in th e a n n e x a tio n
p r o p o s a l.
Names and mailing addresses of each landowner Y e s /N o /N A
11. T h e p r o p o s e d e f f e c t iv e d a te o f t h e a n n e x a t io n . * P le a s e s e e a t t a c h e d i n f o r m a t i o n b u l l e t i n .
Proposed effective date:
12. I d e n t if ic a t io n o f w h e t h e r a n y s p e c ia l c o n d it io n s a r e r e q u e s te d , s u c h a s a s s e s s m e n t a n d
t a x a t i o n p r o v is io n s , c o m p e n s a t io n o r r e v e n u e s h a r in g . * P le a s e se e a t t a c h e d b u l l e t i n .
Conditions:
Taxation Y e s /N o /N A
Assessment Y e s /N o /N A Years: Y e s /N o /N A
Compensation Y e s /N o /N A
Subject to removal clause Y e s /N o /N A
13. R e fe r e n c e to a n y o t h e r r e le v a n t m a t t e r w h ic h a ro s e d u r in g t h e a n n e x a tio n p ro c e s s p r i o r
t o s u b m is s io n o f t h e f o r m a l a p p lic a t io n .
Report accuracy certificate Y e s /N o /N A
Agreed upon issues Y e s /N o /N A
Public consultation activities Y e s /N o /N A
Public consultation summary Y e s /N o /N A
No agreement issues (If required) Y e s /N o /N A
Mediation attempts (If required) Y e s /N o /N A
Reason mediation failed (If required) Y e s /N o /N A
14. O t h e r i n f o r m a t i o n t h a t m a y b e r e q u i r e d o n c e t h e a p p l i c a t i o n is r e v i e w e d b y t h e B o a r d .
Addresses all 15 of the Annexation Principals (MGB Order 123/06) Y e s /N o /N A
Identifies how the public was made aware of the Annexation Agreement Y e s /N o /N A
15. C o n f ir m a t io n o f in v o lv e m e n t o f o t h e r p u b lic in te r e s ts - A I T , S c h o o ls , R e g . S e r v . C o m .,
e tc
Alberta Transportation confirmation Y e s /N o /N A
Confirm Negotiation Report sent to other municipality Y e s /N o /N A
Confirm Negotiation Report sent to other local authorities Y e s /N o /N A
(N o te : A p p l i c a t i o n s h o u l d p r o v i d e r a t i o n a l f o r A lf e 1 S t iM m a t A f ff i f b I&f! f m f;'A nRequeP,a2g0e1N;-o';i;0683

General Description of the Annexation Process
Municipal Government Act Division 6. Sections 112.1 to 128
1. The municipality proposing an annexation must provide notice to the Municipal Government
Board (Board) and to the municipality from which the land is to be annexed. The notice must
describe the lands to be annexed, the reasons for the annexation, and proposals for consulting
with the public and meeting with the owners of the land to be annexed. If the proposal is an
uncontested application pursuant to Section 126 of the Act and the municipality is satisfied that
there is no objection to the proposal from the general public, public consultation is not required.
2. Both municipalities must meet, discuss the annexation proposal and negotiate in good faith. A
negotiation report is then prepared providing a summary of the negotiations and the agreed to
items / conditions of annexation. If there are matters on which there is no agreement between the
municipalities, mediation must be attempted. If mediation failed or did not occur, the reasons for
this must be provided to the Board along with the negotiation report.
3. The negotiation report, all required administrative information and the appropriate fees must be
sent to the Board at which time the proposal becomes an official application for annexation.
4. If the annexation is a simple uncontested application (with signed consents from the landowners
and the responding municipality), the application is processed pursuant to section 126 of the Act,
and the documents are prepared for forwarding to the Minister of Municipal Affairs. However, if
there are no signed consents, the Board must determine whether there is general agreement (i.e.
whether there are any known objections). If the Board decides that there is not general agreement
with the proposed annexation, it will “advertise for objections” with a notification to all interested
parties that objections or concerns must be received by a certain date (usually within a month). If
no objections are received then the Board will not hold a public hearing. The Board will then
forward its report and recommendation to the Minister.
5. If the Board receives objections within the specified time or if the Board finds there is not general
agreement and that mediation attempts have failed, then the Board must conduct one or more
hearings and allow any affected person to appear before the Board at the hearing.
6. The Board’s notice of hearing must be advertised for 2 consecutive weeks in a newspaper which
is circulated in the affected territory.
7. After the hearing, the Board prepares a recommendation for consideration by the Minister.
8. The Lieutenant Governor of Alberta, after considering the Board’s report may, by Order in
Council, approve, approve in part or refuse the annexation proposal. The Order in Council may
list specific conditions of approval if the annexation has been successful in full or in part.
For further information, please contact:

Rick Duncan
Case Manager,
Municipal Government Board - 15th Floor
Commerce Place, 10155 - 102 Street
Edmonton, Alberta, Canada, T5J 4L4.
Direct Phone: 780-422-8652; Fax: 780-427-0986; e-mail: richard.duncan@gov.ab.ca

Page No.00644
In itiatin g M u n ic ip a lity A n n e x a tio n H earing
Date
S ign In S heet
P lease P rin t First and Last N am e C learly
Name Organization Mailing Address Email/Telephone Initial
The information collected on this form will be managed in compliance with the Freedom of Information and Protection of Privacy Act. Questions about the collection of this information can be directed to Alberta Municipal
Affairs, Municipal Government Board, 15lh Floor, Commerce Place, Edmonton, Alberta T5J 4L4,427-4864 (Outside of Edmonton 310-0000 to be connected loll free.)
P age____ o f ______
Page No.00645
Agenda No. Subdivision File No.
Date
Sign In Sheet
Please Print Clearly
Name Name Organization Mailing Address Email/Telephone Initial
(First) (Last)
The information collected on this form will be managed in compliance with the Freedom of Information and Protection of Privacy Act. Questions about the collection of this information can be directed to Alberta
Municipal Affairs and Housing, Municipal Government Board, 15th Floor, Commerce Place, Edmonton, Alberta T5J 4L4,427-4864 (Outside of Edmonton 310-0000 to be connected toll free.)
Page of
Alberta'MuffiSipal Affairs Information Request 2015-R-0088
Page No.00646
Date Intermunicipal Dispute File No.
Sign In Sheet
Please Print First and Last Name Clearly
(First) (Last)
The information collected on this form will be managed in compliance with the Freedom of Information and Protection of Privacy Act and will be used for an anonymous survey. Questions about the collection of
this information can be directed to Alberta Municipal Affairs, Municipal Government Board, 15th Floor, Commerce Place, Edmonton, Alberta T5J 4L4,427-4864 (Outside of Edmonton 310-0000 to be connected toll
free.)
Page____ o f ______
Page No.00647
Date Linear File No.
Sign In Sheet
(First) (Last)
this information can be directed to Alberta Municipal Affairs, Municipal Government Board, 15thFloor, Commerce Place, Edmonton, Alberta T5J 4L4,427-4864 (Outside of Edmonton 310-0000 to be connected toll
free.)
Page____of
Page No.00648
Date DRP File No.
Sign In Sheet
(First) (Last)
this information can be directed to Alberta Municipal Affairs, Municipal Government Board, 15th Floor, Commerce Place, Edmonton, Alberta T5J 4L4,427-4864 (Outside of Edmonton 310-0000 to be connected toll
free.)
Page____ o f ______
Page No.00649
'r NEWH0ME'
newhomN
B U Y E R P R O T E C T IO N
board
Government
Notice of Appeal
New Home Buyer Protection Board (NHBPB)
New Home Buyer Protection (Ministerial) Regulation, s. 8(1)
This information is being collected for the purposes of administering appeal hearings in accordance with sections 33, 39 and 40 of the Freedom of
Information and Protection of Privacy Act. The contact information you provide may also be used to conduct follow-up surveys designed to measure
satisfaction with the appeal process. Questions about the collection of this information can be directed to Alberta Municipal Affairs, New Home Buyer
Protection Board, 15th Floor, Commerce Place, Edmonton, Alberta T5J 4L4 780-427-4864 (outside of Edmonton, call 310-0000 to be connected toll free).
Appellant
Legai Name:
Main Contact Name: (if incorporated)
Operating Name:
NHBPO Builder ID:
Appellant Contact Information (if incorporated, provide information for main corilact person)
Address:
Municipality: Postal Code:
Email: Daytime Phone Number:
Warning: Failure to advise the board of a change of contact information may result in your appeal being dismissed.
Refer to section 24(3) of the Ministerial Regulation for details.
Agent Authorization (leave blank if none)

Agent Name:
Agent Address:
Agent Municipality: Agent Postal Code:
Agent Email: Agent Phone Number:
Matter Under Appeal

New Home Buyer Protection Office File No. For O fficial Use Only
Decision/Order/Penalty No.
Date Received by Appellant: (yyyy-mm-dd)
Appeal Type
J Determ ination o f S tatus Q O w ner-B uilder Authorization Q Exem ption for Hardship
QJ Adm inistrative Penalty Q C om pliance O rder

New H om e Buyer P rote ction Board
NHBPB0001 (2014/01)
Alberta Municipal Affairs Information Request 20TS-W-010§82
Page No.00650
For Compliance Orders Only
I I The A ppellant is nam ed in the com pliance order. Q The A ppellant is not named in the com pliance order.
I | The Registrar has not reviewed the com pliance order.
| The Registrar has reviewed this order and issued decision no.
The Registrar's decision was received on: (yyyy-mm-dd)
Property Details
Street Address: Municipality:
Short Legal Description:
| | The A ppellant owns the property Q The A ppellant does not own the property
If the Appellant does not own the property

Name on Land Title Certificate: Address:
Phone Number: Email:
Grounds for Appeal

Explain what information you believe to be incorrect in the decision/order/penally, if any.
Briefly explain the reason for appeal
Attachments
~| Copy o f decision/order/penalty attached Q Copy o f Registrar's decision attached Q Grounds for Appeal (in a separate attachment)
H Paym ent attached (paper only) Q Paym ent is not attached but will be received by the NHBPB within 7 days
Warning: Failure to pay the prescribed fee will result in the appeal being rejected.
D ig ita l S ig n a tu re In s tru c tio n s
Date (yyyy-mm-dd) Print Name Signature

Send completed forms to:
Email: n h b D b m a ilO a o v .a b .c a OR New Home Buyer Protection Board

15th FI, Commerce Place
10155- 102 St NW
Edmonton, AB
T5J 4L4
NHBPB0001 (2014/01)
Alberta Municipal Affairs Information Request 20i5-R-0~088“
Page No.00651
^ weC h o m N
BOARD
Government
Application for Withdrawal
Appellant Name:
New Home Buyer Protection Board File No.
The Appellant hereby withdraws the appeal of the above-mentioned decision/order/penalty.

Email: nhbpbmail@gov.ab.ca OR New Home Buyer Protection Board

10155- 102 St NW
Edmonton, AB
T5J 4L4
For O fficial Use O nly
New Hom e Buyer P ro te ctio n Board
NHBPB0004 (2014/01)
Alberta Municipal Affairs Information Request 20i5'-!R-0o881
Page No.00652
B U Y E R P R O T E C T JO N
BOARD
Government
______________Joint Recommendation
New Home Buyer Protection (Ministerial) Regulation, s. 25
Appellant
Intervener (if applicable)
Send signed forms to:
New Home Buyer Protection Board

10155- 102 St NW
Edmonton, AB
T5J 4L4
For O fficial Use Only
New H om e Buyer P rote ction Board
Ni L.PB0vjQ8 (.2011 / 0 1 ) Alberta Municipal Affairs Information Request 20iJ5-R-00$8 !

Page No.00653
JdbeA xoi Government

BOARD
_________ Undertaking Re: Confidentiality

In the event that the Board orders that all or part of a hearing on this appeal will be held in private, including if the Board has
already made such an order, I undertake to hold in confidence any evidence heard in private, in accordance with any
applicable Board order and the terms of section 18(3) of the New Home Buyer Protection (Ministerial) Regulation, Alta Reg
220/2013. ' ~
Date (yyyy-mm-dd) Print N am e Signature
Email: nhbpbmail@gov.ab.ca OR New Home Buyer Protection Board

10155- 102 St NW
Edmonton, AB
T5J 4L4
New Hom e Buyer P ro te ctio n Board
NHBPB0006 (2014/01)
Alberta Municipal Affairs Information Request 20)5-^-0088'
Page No.00654
BOARD
Government
________Application for Reconsideration
This information is being collected for the purposes of administering appea! hearings in accordance with sections 33, 39 and 40 of the Freedom of
Information and Protection of Privacy Act. The contact information you provide may also be used to conduct follow-up surveys designed to measure
Protection Board, 15lh Floor, Commerce Place, Edmonton, Alberta T5J 4L4 780-427-4864 (outside of Edmonton, call 310-0000 to be connected toll free).
I | The NHBPB decision/order which is the subject o f this Application for Reconsideration.
i I An explanation of the reason(s) for requesting a reconsideration, (in a separate attachment)
O ther subm issions, (please list)
Paym ent attached, (papersubmissions only)
0 Paym ent is not attached but will be received by the NHBPB w ithin 7 days.
Warning: Failure to pay the prescribed fee will result in the Application for Reconsideration being rejected.

Email: nhbDbmail(a>gov.ab.ca OR New Home Buyer Protection Board
15th Fi, Commerce Place
10155- 102 St NW
Edmonton, AB
T5J 4L4
New Hom e Buyer P rote ction Board
NHBPB0007 (2014/01)
Alberta Municipal Affairs Information Request 2dl5-R-dd881
Page No.00655
board
Government
__________________ Agent Authorization
Information and Protection o f Privacy Act. The contact information you provide may also be used to conduct follow-up surveys designed to measure
Protection Board, 15lh Floor, Commerce Place, Edmonton, Alberta T5J 4L4 780-427-4864 (outside of Edmonton, call 310-0000 to be connected toll free).
Background Information
Name of person authorizing agent:
New Home Buyer Protection Board File No.
Decision/Order/Penaity No.
Agent Information
Agent Name:
Agent Address:
Agent Emaii: Agent Phone Number:
Warning: The NHBPB will accept instructions given by the agent, including instructions to withdrawal from
an appeal.
Email: nhbpbmail@qov.ab.ca OR New Home Buyer Protection Board

10155- 102 St NW
Edmonton, AB
T5J 4L4
For Official Use Only
NHBPB0005 (2014/01) P ja o p J jrfl

Alberta Municipal Affairs Information Request 2015'-«-0088
Page No.00656
BOARD
Government
__________________ Application for Stay
Appellant Name:
New Home Buyer Protection Board File No. (write "TBA" is this form is submitted with a Notice of Appeal)
Explain the reason for the application for the stay of the decision/order/penalty:
Email: nhbpbmail@qov.ab.ca OR New Home Buyer Protection Board

10155- 102 St NW
Edmonton, AB
T5J 4L4
Warning: Section 15(7)(b) of the New Home Buyer Protection Act is not in force.
\HriPELG03 (20l-f.Ul) Alberta Municipal Affairs Information Request 2Oi’5-tR'-00881

Page No.00657
yîherbfu i Government
BOARD
_______________Application to Intervene
Information and Protection o f Privacy Act. The contact information you provide may also be used to conduct follow-up surveys designed to measure
Protection Board, 15th Floor, Commerce Place, Edmonton, Alberta T5J 4L4 780-427-4864 (outside of Edmonton, call 310-0000 to be connected toll free).
Intervener
Legal Name:
Main Contact Name: (if incorporated)
Operating Name:
NHBPO Builder ID:
Intervener Contact Information (if incorporated, provide inform ation fo r m ain contact person)
Address:
Municipality: Postal Code:
Email: Daytime Phone Number:
Warning: Failure to advise the board of a change of contact information may result in your intervention being
cancelled. Refer to section 24(3) of the Ministerial Regulation for details.
Agent Authorization (leave blank if none)
Agent Name:
Agent Address:
Agent Email: Agent Phone Number:
Matter Under Appeal

NHBPB File No.

New Home Buyer Protection Office File No.
Date Received by Intervener: (yyyy-mm-dd)
Appeal Type
I | Determination of Status Q Owner-Builder Authorization Q Exemption for Hardship
J Administrative Penalty Q Compliance Order New Hom e Buyer P rote ction Board
NHBPB0002 (2014/01)
Alberta Municipal Affairs Information Request 2015-R'-008ff
Page No.00658
For Compliance Orders Only
J The Intervener is nam ed in the com pliance order. Q The Intervener is not named in the com pliance order.
J The Registrar has not reviewed the com pliance order.
] The Registrar has reviewed this order and issued decision no.
The Registrar's decision was received on: (yyyy-mm-dd)
Property Information
J The Intervener owns the property
] The Intervener does not own the property
Grounds for Involvement

Explain how your rights may be affected by a decision of the Board on appeal:
Explain the nature and scope of your intended participation:
Explain how you want the appeal to be resolved:
Explain why the Board should decide in the manner you want:
Attachments
~2 G rounds for involvem ent (in a separate attachment)
Paym ent attached (paper submit only) Q Paym ent is not attached but will be received by the NHBPB within 7 days
Warning: Failure to pay the prescribed fee will result in the Application to Intervene being rejected.
Email: nhbpbmail(5)qov.ab.ca OR New Home Buyer Protection Board

10155 —102 St NW
Edmonton, AB
T5J 4L4
NHBPB0002 (2014/01}
Alberta Municipal Affairs Information Request 20l'5-R-0(0882
Page No.00659
M u n ic ip a l G o v e rn m e n t B o a rd - G e n e ra l
U s e r P r o fi le f o r
DOB (MM/DD) * |[ C ity/Tow n o f Edmonton

R esidences *
Primary Email '
P rov/R egion * ^g
Prim ary Ph. # ' 780-427-4864 „

Z ip/P o sta l Code
Secondary Ph. #
C o un try o f R esidence Canada
Sec. Ph. # Ext.
Secondary Email
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Page No.00660
RETURN TO:
Pjg; Municipal Government Municipal Government Board Notice of Appeal for
a i Board (MGB) 15"1Floor Commerce Place 1 0 1 5 5 - 102 Street
Edmonton AB T5J 4L4 Equalized A ssessm ent
Telephone: 780-427-4864 Fax: 780-427-0986
Email: mobmail@Qov.ab.ca
Appeal
Per sections 321 and 491 of the Municipal Government Act (Act), a municipality may make a complaint about the amount of an
equalized assessment to the Municipal Government Board not later than 30 days from the date the Minister sends the municipality
its annual report {described in section 320) of all the equalized assessments prepared.
P a rt 1 - C o n ta c t Inform ation - P le a s e P rin t
APPELLANT MUNICIPALITY
Name of Municipality Telephone Number
Designated Contact Position fe.g, C.A.0.)
Address (Street, PO Box, RR) (Town/City/Vitlage) (Province) fPosta/ Code)
AGENT INFORMATION (if Appellant is Represented by a Lawyer/Agent)

Name of Firm
Address {Street, P0 Box, RR) (Suite, Apartment) (Town/CityA/illage) (Province) (Postal Code)
MUNICIPALITY for Which Equalized Assessment is Under Appeal (if Different from Above)
Name of Municipality Telephone Number
Designated Contact Position (e.g. C.A.O.)
Address (Street, P0 Box, RR) (Town/CityA/illage) (Province) (Postal Code)

Page No.00661
P a rt 2 - R e a s o n the Matter is B e in g R e fe rre d to the B o a rd
Please explain why you are appealing the equalized assessment. Why do you think it is incorrect (attach more pages as necessary),
P a rt 3 - E x p la n a tio n o f Is s u e s to be D e cid e d by the B o a rd

Please explain what issues the Board will need to address as a result of your appeal (attach more pages as necessary)
Please attach a copy of the notice sent to the municipality prior to the second reading.
P a rt 4 - R e q u e ste d A s s e s s m e n t A m o u n t
Please explain in what respect the equalized assessment amount is incorrect and what the correct assessment should be.

This information is being collected for the purposes of setting up appeal hearings in accordance with Section 33(c) of the Freedom of information and Protection of Privacy
Act. The contact information you provide may also be used to conduct tollow-up surveys designed to measure satisfaction with the appeal process. Questions about the
collection of this information can be directed to Alberta Municipal Affairs. Municipal Government Board. 1 &” Floor. Commerce Place, Edmonton, Alberta T5J 4L4

Page No.00662
EXHIBIT NO.
MGB FILE NO. Q

HI
A LINEAR A SSESSM EN T COMPLAINT §

-OR- lu
AN EQUALIZED ASSESSM EN T aL
IN THE MATTER OF COMPLAINT
FO R M G E U S E O N LY
COMPLAINANT
RESPONDENT
DOCUMENT
NAME
(ORGANIZATION)
AD D RESS FOR
SERVICE
EMAIL
TELEPHO NE
(FOR PERSON FILING

THIS
DOCUMENT)

Page No.00663
. Municipal Government RETURN TO:
Municipal Government Board Notice of
& A Board (MGB) 15lh Floor Commerce Place 1 0 1 5 5 - 102 Street
Edmonton AB T5J 4L4 Annexation
Telephone: 780-427-4864 Fax: 780-427-0986
Email: mobmail@gov.ab.ca Application
Web URL: http://www.mgb.alberta.ca
Please indicate whether the initiating and responding municipalities and the public are
generally in agreem ent with the application for annexation.
A copy of this form should be attached with your annexation application together with the
material marked with an S in the corresponding column below:
i i Yes (There is general agreement)------------- ----------------------------------------------

□ No (There is no general agreement)--------------------------------------,
No General General
Item
Agreement Agreement
A clear statem en t th a t the initiating m unicipality w ishes to proceed
w ith the annexation and intends the re p o rt to becom e the
application for the annexation.
Application Fee (Cheque payable to th e G overnm ent of Alberta)

$300 for first quarter; $50 for each additional qtr. or portion of qtr.
An up-to-date m ap show ing the location of th e existing municipal

boundary and the proposed m unicipal boundary, w ith each parcel v'
to be annexed identified by legal land description.
All relevant sections of any Municipal D evelopm ent Plan o r o th er

v'
S tatutory Plan.
A description of the intended uses for th e annexation area

including a description of how the area can be serviced w ith w ater, s
sew er, storm sew er and other related m unicipal services.
The signed consent, w ithout conditions, of each ow ner of land th a t

is w ithin the intended annexation area.
A signed acknow ledgm ent from each ow ner of land th a t is w ithin

the intended annexation area th a t they are aw are of and accept all
assessm en t and taxation conditions.
A le tte r from the responding m unicipality w ritten on municipal

letterhead and signed by an a p p ro p riate m unicipal official that
• Certifies agreem ent to the annexation.
Effective January 1 ,2013 19 Annexation

Procedure Rules
Page No.00664
No G eneral G eneral
Item
A greem ent Agreem ent
A letter from the initiating municipality written on municipal

letterhead and signed by an appropriate municipal official that
✓
• Certifies there are no known objections from the general
public.
An explanation of the consultation process followed. ✓ ✓
An explanation of any differences between the public consultation

process followed and that proposed in the notice filed with the ✓ ✓
Board under section 116.
A clear identification of which boundary roads are to be included ✓ S

or excluded in the annexation.
Up-to-date copies of land title certificates for each parcel proposed

to be included in the annexation. The certificates must have been
✓ S
issued within six months of the Board's receipt of the application,
unless otherwise agreed to by the Board.
A list of the names and mailing addresses of each landowner (with

their corresponding parcel identified) and any other person known V
to have an interest in the annexation proposal.
The proposed effective date of the annexation. If this date is

retroactive to the anticipated annexation order, an explanation as S ✓
to why a retroactive date is necessary.
Identification of whether any special conditions are requested,

such as assessment and taxation provisions, compensation or S S
revenue sharing.
Reference to any other relevant matter which arose during the S S

annexation process prior to submission of the formal application.
Confirmation of involvement of other public interests, including ✓ S

Alberta Transportation, schools, and utilities, etc.
List of the affected local authorities (as defined under

section 1(1) (m) of the Act) to which the applicant has provided a
copy of the application pursuant to section 119(1) of the A c t
including
♦ Municipal authorities, ✓ ✓
♦ Regional health authorities, regional services commissions,
and
♦ Boards of trustees of the local school district(s) or
division(s).
Effective January 1,2013 20 Annexation
Procedure Rules
Page No.00665
No G eneral G eneral
Item
Agreem ent A greem ent
An explanation of how the proposed annexation addresses each of ✓ ✓

the principles listed in Appendix "B".
An explanation of any agreed-to compensation agreement ✓ S
Financial Analysis. ✓ S
Effective January 1,2013 21 Annexation

Procedure Ruies
Page No.00666
RETURN TO: Municipal
Municipal Government Government Board Notice of
» Board (MGB) 15lh Floor Commerce Place 10155 - 102 Street
Edmonton AB T5J 4L4 Subdivision
Telephone: 780-427-4864 Fax: 780-427-0986
Email: mqbmail@aov.ab.ca Appeal
As per section 678(1) of the Municipal Government Act (Act), the decision of a subdivision authority on an application for subdivision
approval may be appealed (a) by the applicant for the approval, (b) by a government department if the application is required by the
Subdivision and Development Regulation to be referred to that department, (c) by the council of the municipality in which the land to be
subdivided is located if the council, a designated officer of the municipality or the municipal planning commission of the municipality is
not the subdivision authority, or (d) by a school authority.
P a rt 1 - G e n e ra l Info rm ation - P le a s e P rin t
A notice for subdivision appeal under section 678 of the Act should contain the following information and must be filed within 14 days
after receipt of the written decision of the subdivision authority or deemed refusal by the subdivision authority in accordance with
section 681,
G il Highway!#.................) D Water Body (Name, if n a m e d ............................................ ) O Landfill O Sewage Treatment Facility O Green Area
Legal Description Lot Block Plan AND/OR Portion Section Township Range Meridian
APPELLANT (Landowner or department lodging the appeal)

Address (Slreet, PO Box, RR) (Suite, Apartment) (Town/CityVillage) (Province) (Postal Code)
LANDOWNER INFORMATION (if different from Appellant)

Address (Sfreer, PO Box, RR) (Suite, Apartment) (Town/Cily/Viliage) (Province) (Postal Code)
AGENT INFORMATION AND CERTIFICATION (if Appellant is Represented by an Agent)

Address (Street, PO Box. RR) (Suite, Apartment) (Town/CityA/illage) (Province) (Postal Code)
1(We) hereby authorize to act on mv (our) behalf on matters pertaining to this subdivision appeal
Signature of Owner(s) Date Signature of Owner(s) Date

P a g e 24 Alberta Municipal Affairs Information Request 2015-R-0088
Page No.00667
P a rt 2 - D e c is io n o f the S u b d iv is io n A uthori

year month day
P a rt 3 - R e a s o n s fo r A p p e a l
As per section 678(4) of the Municipal Government Act, all subdivision appeals must include the reasons for appeal, including the
issues in the decision or the conditions imposed in the approval that is the subject of the appeal. (Attach extra page(s) if required)
CH Approval - Which of the conditions of approval are under appeal and what are your reasons for disagreeing with those
conditions? OR
dll Refusal - Please give the reasons why you think your subdivision application should be approved?
P a rt 4 - P re -H e a rin g M eetings
It is recommended that you discuss your appeal with the Subdivision Authority, Alberta Transportation, Alberta Sustainable
Resource Development, and Alberta Environment and Water (if applicable) prior to the appeal hearing.
Did you discuss your appeal with a representative from the Subdivision Authority? □ YES □ NO
Did you discuss your appeal with a representative from Alberta Transportation? □ YES □ NO
Did you discuss your appeal with any other agencies or departments? □ YES □ NO
If yes, please specify

Act The contact information you provide may also be used to conduct follow-up surveys designed to measure satisfaction with the appeal process. Questions about the
collection of this information can be directed to Alberta Municipal Affairs. Municipal Government Board. 1$h Floor, Commerce Place, Edmonton, Alberta T5J 4L4
780-427-4864. (Outside of Edmonton call 310-0000 to be connected toll free)

Page No.00668
RETURN TO:
Municipal Government Municipal Government Board Notice of Appeal for
Board (MGB) 15ln Floor Commerce Place 10155 - 102 Street
Edmonton AB T5J 4L4 Intermunicipal
Telephone: 780-427-4864 Fax: 780-427-0986
Email: mqbmail@aov.ab.ca Dispute
Web URL: http://www.mQb.alberta.ca
As per section 690(1) of the Municipal Government Act (Act), a municipality that
1. is of the opinion that a statutory plan (or amendment) or a land use bylaw (or amendment) adopted by an adjacent
municipality has or may have a detrimental effect on it,
2. has given written notice of its concerns to the adjacent municipality prior to second reading of the bylaw, and
3. is attempting or has attempted to use mediation to resolve the matter
may appeal the matter to the Municipal Government Board. A statutory declaration indicating the status of mediation must
accompany this Notice of Appeal. The Notice of Appeal and Statutory Declaration must be filed with the MGB within 30 days after
the passing of the bylaw to adopt or amend the statutory plan or land use bylaw.
P a rt 1 - G e n e ra l Info rm ation - P le a s e P rin t
APPELLANT MUNICIPALITY
N am e o f M unicipality T e lep h o ne N um ber
D esignated C o n ta ct P osition (e.g. C.A.O.)
A d d re ss (Street, PO Box, RR) (Town/City/Village) (Province) (Postal Code)
E -m ail A ddress Fax N um b e r
AGENT INFORMATION AND CERTIFICATION (if Appellant is Represented by a Lawyer/Agent)

N am e o f Firm
D esig n ated C on ta ct (Last) (First) T e le p h o n e N u m b e r (daytime)
A d d re ss (S treet, P 0 Box, RR) (Strife, Apartment) (Town/City/Village) (Province) (Postal Code)
E -m ail A ddress Fax N um ber
ADJACENT MUNICIPALITY
N am e of M unicipality T e lep h o ne N um ber
D esignated C o n ta c t (e.g. C .A O .)
A d d re ss (S tre e t PO Box, RR) (Town/CityA/illage) (Province) (Postal Code)
E -m a i! Address Fax N um b e r

Page No.00669
P a rt 2 - O w n e r(s ) o f Land th a t is th e S u b je c t o f th e A p p eal
(If m ore than one o w ner, please attach list o f th e nam es and ad d resses o f each lan do w ner of any land that w ill be
directly affected by this appeal)
Name (Last) (First) Telephone Number (daytim e)
Address (Street, P 0 Box, R R ) (Suite, Apartment) (T o w n/C ity/V illag e ) (P rovince) (P o sta l Code)
P a rt 3 - B y law In fo rm atio n (all to be completed)

Please indicate which bylaw is under appeal
Oate bylaw received second reading Date bylaw passed
Please attach a copy o f the notice s e n t to the m u n icip ality p rior to the second reading.
P a rt 4 - R e aso n s fo r A p peal
Indicate the specific provisions appealed and the reasons you think they are detrimental (attach more pages as necessary).

Act. The contact information you provide may also be used to conduct follow-up surveys designed to measure satisfaction with the appeal process. Questions about the
collection of this information can be directed to Alberta Municipal Affairs, Municipal Government Board, 15?h Floor. Commerce Place, Edmonton, Alberta T5J 4L4

Page No.00670
RETURN TO:
ppgi Municipal Government Municipal Government Board Statutory
^ Board (MGB) IS1" Floor Commerce Place 1 0 1 5 5 -1 0 2 Street
Declaration
Edmonton AB T5J 4L4
Telephone: 780-427-4864 Fax: 780-427-0986
Email: mqbmail@gov.ab.ca {Intermunicipal Dispute
Web URL: http://www.mqb.alberta.ca Appeal)
I _______________ of DO SOLEMNLY DECLARE THAT:

(Name)
1. wishes to file an Appeal with the

(Appellant Municipality)
Municipal Government Board concerning , and that

(Bylaw provision under appeal)
2. I am th e _________________________of the__________________________________ , and that

(Position) (Appellant Municipality)
3. (Please choose one of the following)

(a) Mediation with (adjacent municipality) was not undertaken □
(b) Mediation was undertaken but was not successful □
(c) Mediation is ongoing and the appeal is being filed to preserve the right of appeal □
4. And further, the reasons why mediation was either not undertaken or not successful
are as follows in Attachment "A" (please tick N/A if option (c) was selected), □ N/A
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.
(Signature of Appellant OR (Print Name)

Person Authorized to Act on Behalf of Appellant)
DECLARED BEFORE ME AT _____________________
in the Province of Alberta, this __________________ day
o f__________________________________, 2________
(Commissioner for Oaths) (Print Name)
(Expiry Date of Commission)
Act- The contact information you provide may also be used to conduct follow-up surveys designed to measure satisfaction v/ith the appeal process. Questions about the
collection of this information can be directed to Alberta Municipal Affairs, Municipal Government Board, 15'" Floor, Commerce Place, Edmonton, Alberta T5J 4L4

Page No.00671
EXHIBIT NO.
MGB FILE NO. I o

.. . . . . . . . . . . . . . . . . j i*i
; >
IN THE MATTER OF AN INTERMUNICIPAL DISPUTE 1

o
III
1 cr
INITIATING
i
MUNICIPALITY i
---------------------------------------------------------------------------------------------------------------1 FOR MGB USE ONLY
1 :
RESPONDENT
MUNICIPALITY
DOCUMENT
NAME
(ORGANIZATION)
ADDRESS FOR
SERVICE
EMAIL
TELEPHONE
(FOR PERSON FILING

THIS
DOCUMENT)

Page No.00672
A ss essm en t R e v ie w B oard (ARB) O n lin e E ven t R e g is tra tio n S ystem
ARB C lerk - N e w M e m b e r /C le r k R e fre s h e r C ourse

ARB M e m b e r - N e w M e m b e r Course
ARB M e m b e r - M e m b e r R e fre sh e r C ourse
ilirte Majuwi... d Dictionary.com d MyAGent fff] Legal Files Web For M,„ ifj) Dictionary ▼ [J * '
3105* 16th Avenue North To: 4pr 12,2016 04 00PM

Lethoridge AB
Municipal Government Board Office From: Apt 13,2016 08 30AM

50J 520 7th Avenue SW, J J Bo*len Building Tffi Apt 14 2016 04 00PM
Calgary AB
Romero. Hotel and Conference Centre Front Apr 10 2016 08 30AM

11633- 100th Street To: Apr 20 2 0 1 6 04 00PI.I
Grande Frame AB
Red Deer Lodge Hotel and Conference Centre From: May 24,2016 03 30AM
4311-J9th Avenue To: May 25 2016 04 00PM
Red Deer AB
Municipal Government Board Office From: May 26 2016 08 30AM

504.620 7th Avenue SW J J Bowten Building To: May 2 7 .2016 04 O0PK1
Calgary AE
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Page No.00673

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PART A - IDENTIFICATION AND PURPOSE

Office Address Telephone Number

Identify other persons accompanying (if any)

Destination Method of Travel Departure Date (yyyy/mm/dd) Return Date (yyyy/mm/dd)

Signature of Employee Date Signature of Division Head Date

PART B - ESTIMATED EXPEND TURES

PART C - AUTHORIZED SIGNATURE

Deputy Minister Date

Traveller Recommend Approve

Department Staff Assistant Deputy Minister / Equivalent Deputy Minister

MGB M em ber/Staff MGB Chairman Deputy Minister

PART A - IDENTIFICATION AND PURPOSE

Office Address Telephone Number

Identify other persons accompanying (itany)

Signature of Employee Date Signature of Division Head Date

PART B - ESTIMATED EXPENDITURES

PART C - AUTHORIZED SIGNATURE

Deputy M inister Date

Expenditure Officers are responsible for:

A P P R O V A L : As of March 1, 2003, a Criminal Record Check is required of new Expenditure Officers,

Forward this form to:

Solicitation Number: (if applicable) Legal Name of Contractor/Consultant:

Is this a new capital asset? 0 Yes 0 No If "Yes", identify Project Name

Is this an enhancement to 0 Yes 0 No If "Yes", identify Project Name

Non-Canadian Contractor 0 Yes 0 No If "Yes", retain 15% Federal witholding tax.

Contract Manager Date (yyyy-mm-dd) Signature

Direct Report to DM (if<$i,ooo.ooo) Date (yyyy-mm-dd! Signature

SFO (if >$1,000,000) Date (yyyy-mm-dd) Signature

Section 1: Contracting Summary

Contract Term (Include all estimated extensions) Desired Contract

Division / Branch Contract Manager

Section 2: Rationale for Contracting

Scope of the Work and Deliverables

Program Area Response (limit to one sentence)

Form version: 20150901 Alberta Municipal Affairs Information Request 2015-R-0088

Direct Report to Deputy Minister

Section 4: Additional Information or Comments

Form version: 20150901 Alberta Municipal Affairs InfofmgJioncRequest 2015-R-0088

Section 1: Contracting Summary

Amendment Amount (Include all costs, labor and expenses.)

Total Contract (Original Value + Amendment)

Section 2: Rationale for Amendment

Scope of the Work and Deliverables

Program Area Response (limit to one sentence)

Form version: 20150901 Alberta Municipal Affairs Information Request 2015-R-0088

Can the work be delayed? What are the risks?

Section 3: Additional Information or Comments

Direct Report to Deputy Minister

Contract Review Committee

Senior Financial Officer

Amendments must be reviewed by Legal Services prior to being sent to vendors.

Form version: 20150901 Alberta Municipal Affairs Information [Request 2015-R-0088

Section 1: PQR Summary

PQR Information Please include a copy of the following:

Division / Branch PQR Administrator

Section 2 : Rationale for Source List

Overview of the Possible Work

Program Area Response (limit to one sentence)

Section 3: Additional Information or Comments

Form version: 20150323 Alberta Municipal Affairs Information Request 2015-R-0088

Direct Report to Deputy Minister

Contract Review Committee

Form version: 20150323 Alberta Municipal Affairs InformationRequest 2015-R-0088