t >Ontario CJft $L5 Financial Statement Auditor s Report Form 4 Municipal Elections Act, 1996 (Section 78) $ Io1-S.S S $ 4C).

Transcription

1 t >Ontario Ministry of Municipal Affairs and Housing Financial Statement Auditor s Report Form 4 Municipal Elections Act, 1996 (Section 78) Instructions All candidates must complete Boxes A, B,, D, E and F and Schedule 1. All candidates must complete Schedules 2, 3 and 4 as appropriate. andidates who receive contributions or incur expenses in excess of 1, must also attach an Auditor s Report. All surplus funds (after any refund to the candidate or his or her spouse) shall be paid immediately over to the clerk who was responsible for the conduct of the election. Box B: Summary of ampaign Income and Expenses YYYY MM DD YYYY MM DD For the campaign period from (day candidate filed nomination) O 9 I O to OI I. 3 I ary filing reflecting finances to December 31 (or 45 th day after voting day in a byelection) Supplementary filing including finances after December 31 (or 45 th day after voting day in a byelection) Box A: Name of andidate and Office Name of andidate Last Name First Name Middle Initial. Lô Mailing Address Suite/Unit No. Street No. Street Name cl ity/town Province Postal ode oo ills Telephone No. (md. area code). Fax No. Address Business Home o Sq z nz j.ej LLL,S m&l. U1T Name of office for which the candidate sought election ôj Name of Municipality Jft Ue Ward l! ame or No. (if any) 1. My spending limit (as issued by clerk) was 2. Surplus (or deficit) from previous election Io1S.S S t/ 3. Total contributions received (from Schedul 1) 4. My total campaign expenses that were subject to the spending limit were (from Box ) 4).\ 5. My total campaign expenses that were not subject to the spending limit were (from Box ) 6. Total of all campaign expenses (from Box ) 7. Election campaign surplus/deficit from current election (from Box E) 8. ontributions refunded to candidate or spouse (from Box E) 9. Amount paid to clerk (from Box E) \ 4 L5 953P (21/1) Queen s Printerfor Ontario, 21 Disponible en francais Page 1 of 8

2 Box : Statement of ampaign Period Income and Expenses From To For andidate MM DD MM DD Total ampaign Period Income 3. Other (provide full details) 1. \ô;. k INOME andidates surplus from immediately preceding election released by the clerk 6 b ontributions from candidate ontributions from spouse of candidate All other contributions Revenue from fundraising functions not deemed a contribution (ñom Schedule 2, Part Ill) Interest income Other (provide full details) EXPENSES (Note: include the value of contributions of goods and services) Expenses Subject to Spending Limit Advertising Bank charges Brochures Interest on loan Inventory contributed to candidate s campaign (Schedule 3) Meetings hosted Nomination filing fee Office expenses Phone and/or Internet Salaries and bnefits/honoraria/professional fees Signs Other (provide full details) 1.Lt\ c:b 2. Ex* k\c Ac ac ccrs Subtotal = Expenses Not Subject to Spending Limit Accounting and audit osts of fundraising function (from Schedule 2, Part IV) Expenses related to compliance audit Expenses related to controverted elections Expenses related to recounts Voting day party / appreciation notices Expenses related to candidate s disability (provide details) i i 1 k 1. crn 1k& c*j 2. Jr4Vte d *o 3. Accc I Subtotal = Total ampaign Period Expenses (2) (3) Excess (Deficiency) of Income over Expenses (l) (4) O S O L. 4O3L1c SO. icc çss. 4L4.. L4cO.4 S & 1cscD (D2 4.lO 32 qc( =I id L lzci5(, 2 3 =(plo 4 = o. q 953P (21/1) Page 2 of 8

3 Box D: Statement of Assets and Liabilities as at 2 Assets ash Accounts receivable Value of inventory retained (from Schedule 4) Other (provide full details) 1..y. p.vs Total Assets q\. 4, :f1 lt:3 \D%:e 4 Liabilities and Excess (Deficiency) of Income over Expenses Accounts payable Borrowings, overdraft Other (provide full details) Total Liabilities c o.t s ) = Is (r Box E: Statement of Determination of Surplus or Deficit and Disposition of Surplus Part I Determination of Surplus or Deficit Amount of excess (deficiency) of income over expenses (from Box ) Deduct: Any deficit carried forward by the candidate from immediately preceding election if the offices are with respect to the same jurisdiction Surplus (or deficit) for the campaign period (El) (E2) = Deduct: Any refund of contributions to the candidate or spouse (only if there is a surplus) TotalDetermination. = cc El ( cc 2 V3 L( E3 Part II Disposition of Surplus If line E3 shows a surplus, the amount must be paid in trust, at the time the financial statements are filed, to the municipal clerk who was responsible for the conduct of the election. Surplus paid to the municipal clerk of the municipality of Box F: Declaration i_jl 4L, a candidate in the municipality of ( ltj ç (jrjc..c,jae_. hereby declare that to the best of my knowledge and belief that these financiai statements and attached supporting schedules are true and correct. Declared before (clerk or commissioner) (J.I } o 8h5ckVi/)e ão/ Signatvre of lerk or ommissioner on (yyyy/mm/dd),5 /r?die 41 J Date Filed in the lerk s Office (yyyy/mm/dd) Siliature of andidate I : 953P (21/1) Vlckj Baker, a ommissioner, etc. Province of Ontario, for the orporation of the ity of Brockvijle. Expires June 3, 216. Page 3of8

4 Schedule I ontributions 1 Part I ontribution ontribution from candidate ontribution from spouse Total from each single contributor totalling more than 1 include all ticket revenue where ticket price exceeds 1 include all goods and services where value exceeds 1 * do not include contributions from candidate or spouse Total from each single contributor totalling 1 or less include all ticket revenue where ticket price is 1 or less include all goods and services where value is 1 or less* do not include contributions from candidate or spouse *Note: Goods and services must also be reported as expenses in Box Less; ontribution returned or payable to the contributor ontribution paid or payable to the clerk Total Amount of ontribution Total contribution from anonymous sources Amount of contributions paid or payable to the clerk (IA) (IB) c c LLb&,,c jlk rr.:tc: \ IA lb Part II List of ontributions from Each Single ontributor Totalling More than 1 Table 1: Monetary contributions from individuals other than candidate or spouse Name Address Amount ca c1cric. D FL, Rcre t\ke n \ p J I\r 1 b bo I I,.. e 4 1c 3 wôoó Sps Aac\ ô tkiacl _) I 4chax _) T1 c3cr jôe. Seà% 8x c rsor. S& o ed 4M 1 Ps \ LcS o 6m cb 5 z5c2 ktee Ork L (d S c. e. O toe(o 2Li.cS Paó it bke 37 5o L81 clx c A. 1 (S kli eb\ 1 &e.& <fjl4(1 5Y Pit.x odje.s 5r 9 S The&ce Lo e &o c s1e.ê g i:alr U Its eôn. q ea. ( Ieo p& &c ek *trb 3T (o t t\ \,.. j LLI \ J MS c5ce s WqM ditional information is listed on separate supplementary attachment Total J co t: tjl 953P (21/1) Page 4 of 8

5 i 95 \c4jioc 4 fi4 cc.rsscyr Zcø 3 4Ae# 411* I 2i1/ 4 LJ edr\erj \owk jo e1 &( teek o. j Vci 3S & \ LSc35c * srux (24 8 OS bce) t A Tc,crc o 9 t* % V/ii &j 4s o 7e,c Sce k ( 4 ca.,cj #.J c3 ZS DOYW1 U c cs cwa esce.,%k) c,j\\ke. ô Aac ç* (L)t Jgrcjr (o r. o\ P\ tth) 1\ L e< ç \ ç..j*e.o 4. tvrl Q t4,sls pjbo P 7;, The I c D AD o Le e ic 5y çç oc Sirrv\ &9c re & &ô ;Ju vii t*, LO tad z. cssu 1 4 aô Sr ec% ObS if*o

6 QL cxyw \cz 3er à c% O1 &3O )er 25 L & 4J c, O 1 4(L M&c t& 4v% e. ( 4 cà.e. rke Uz \Jc c\cooac cy%ce.f4 3z o rc3oi t ie, WL urkqà 2j Orw c ci 3 (& I jd J SD b(d ST cc e.& Ec, cse 5esz\e 2 i cb 4O 5Z4 oc E.cacL L1oS s 52(pS cuck (jc _c c Qcc\ \ø, ITo y yrcr 4 (IL e,ce Loydj o ccerc c, çe_ exe, O4 2 T?cç4 tk8a3r &:1j sc3 es cj dz pr\ ircjr )51 rost2 3(t(jL4 4. Pcck O1 rç 25 U S14 i#a,ol 3Sac 5 O) 8 &V Pie) Tororr¾D 1 1c L4Uç bea LDe &.?a, I 1<1 5 ri c 3

7 /ili fl\ IV* cs3 so rr ck ts 3?çe rcia So r LSicj\. LLXSf Ecsrc 1L.j c?ô. ojc 4 I 6tsx \L j S&c T* o ( AS L3 4 Se,Qc b fjl 8 c&r s Sc iqco lpa4) k c* is& 3E.i 5c* crji4 o # Terve ôt. J tfrj * O r c?rj SS kc E, %\i bc J I kexo Lj S kijafs ecju i SF 44 o Lcuces c c c & FW( 2SZ E*ce Greôr ei jf L Z \7. I jsj ere3 ds \ i 3X3O P ir..oea 1?c ) Sce J LT8 41o ilwdc cjçr 4e &c elj u,ocd tn.u ix O TuL (jl keo j,j.,j e 4 9ss 4 k e* I2 I i 4 s rrør bas S J SAl 4 zj

8 1 s. c_ j h oc ill 2v9._o o t, rj F I. d L L34 oa.. a U, I U _% e I l) ti j q. O e2 ç3, TI. S?Q oo 1) 8 8

9 o I a., S U, 4 u D m D i, 8

10 c1 2 ; c. *fl( V t t.j r II II D. 1) ( 3 ( 3 a. a D c >a > ( 3 E.) ( 3 ( 3 G) ( 3 > c ( 3 D o ( 3 D o ( 3 < w Ii > D 1E E 1> 1 Q : a. j D ci) ci).) E ( OQ) 8 Eg D.a ( 3 1 a D :2 9 ( 3 E cj.) U a.. ci) )) G U O D D Q) ) O w D) SE ( 3 w G) 3 ) = ) a. x w > E (I) I a.. = = < Z Di a.a. j D cc ( a. o I )., c, ).) LI ) o LI..1.)

11 ( _) p cp c) 3 24 r 3 3 L 1 : Q 1 1 DP (rj L 9 ii9 7, p _fr QD r ct. (I? Zr M ii I

12 3 s. ) 31 1 ii (Q) 1

13 ir,s 13 1.o a

14 Lchedule 3 Inventory of ampaign Goods and Materials (from Previous ampaign) Used in andidate s ampaign Total Value of Inventory from Previous ampaign Used in andidate s ampaign Schedule 4 Inventory of ampaign Goods and Materials at The End of ampaign Description Date Acquired Supplier Unit Value Quantity Total Value (yyyylmmldd) L3s oo 1c\ Lurc3 5O 3S 1L)Q S Total Value of Inventory of ampaign Goods and Materials 953P (21/1) Page 7 of 8