For broodmares, whose owners reside outside Prince Edward Island and who were on Prince Edward Island for a minimum of 183 days in the foaling year and whose offspring are being nominated to the Lady Slipper/Joe O’Brien Stakes. Nominations are subject to the terms and conditions of the Lady Slipper/Joe O’Brien Stakes as approved by the Atlantic Provinces Harness Racing Commission. The deadline to submit this form will be December 1st, 2024.

C A N A D A PROVINCE OF PRINCE EDWARD ISLAND IN THE MATTER OF: The Prince Edward Island Lady Slipper/Joe O’Brien Stakes. I, (Typed Name Below), of (Address above), in the Province of Prince Edward Island, Farm/Property Owner/Manager do solemnly declare that:

1. I am the person who owns or did own/manage the farm/property on which the broodmare(s) described in the Broodmare Declaration Form (reverse) resided during the last calendar year.

2. The matter and facts in the Broodmare Declaration Form are true, to my own knowledge; and

3. I understand in the case of information in the Broodmare Declaration Form not being correct that the mare described therein would be declared ineligible for the Prince Edward Island Lady Slipper/Joe O’Brien Stakes and my farm/property or I would be liable to reimburse all purse money earned by the farm, myself or the buyer of the applicable offspring and my farm or I would be ineligible to participate in the Prince Edward Island Lady Slipper/Joe O’Brien Stakes in the future. And I make this solemn declaration conscientiously believing it to be true and knowing that it is of same force and effect as if made under oath.

County of Canada, Prince Edward Island,)
Name and Signature of Farm/Property Owner/Manager