STATUTORY DECLARATION A

STATUTORY DECLARATION A

CANADA
PROVINCE OF
BRITISH COLUMBIA

IN THE MATTER OF SECTION 933(8}(a) OF THE
LOCAL GOVERNMENT
ACT AND
CITY OF
LANGFORD
DEVELOPMENT
COST
CHARGE
BYLAW NO. 1401

I, ____________________, of ____________________, Langford, in the Province of British Columbia, DO SOLEMNLY DECLARE:

1. I am the owner of land in the City of Langford legally described as ____________________ (the "Land").

2. I have applied to subdivide or develop the Land and the subdivision or development of the Land imposes a capital cost burden on the City in relation to park land.

3. On [insert date of payment] I paid to [insert name of owner who constructed DCC Project] the amount of $____________________ as a contribution towards the cost of [identify DCC Project].

4. I make this Statutory Declaration for the purpose of requesting the City to allow a setoff of the amount specified in paragraph 3 against development cost charges for which I am liable in respect of the development of the Land under the City's development cost charge bylaw.

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 and by virtue of the Canada Evidence Act.

SWORN BEFORE ME at the City of Langford, in the Province of British Columbia, this ______ day of ___________________, 201.

A Commissioner for Taking Affidavits in the Province of British Columbia

[insert name of owner]

[insert name of owner]