IPostal Code. t?ontario. c:rsupplementary filing including finances after December 31 (or 45'" day after voting day in a by- Iection) ri:-

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1 ri:- t?ontario...istry of Municipal Atfalnl and Housing ?;:; ;:orj 1. 1 ~~,. I Financial Statement - Auditor's Report Fonn4 Municipal Elections Act (Section 78) Instructions All candidates must complete Boxes A, B. C, 0, E and F and Schedule 1. All candidates must complete Schedules 2. 3 and 4 as appropliate. Candidates who receive contributions or incur expenses in excess of 10,000 must also attach an Auditor's Report. All surplus funds (after any refund to the candidate or his or her spouse) shai be paid immediately over to the clerk who was responsible for the conduct of the election. yyyy MM DD yyyy MM DD For,e campaign period from (day candidate filed nomination) I 2010 I 01 I 05 to L--2_0_1_1--L.._0_3_...l..._2_5_...l ~ ynmary filing reflecting finances to December 31 (or 45'" day after voting day in a by- Iection) c:rsupplementary filing including finances after December 31 (or 45'" day after voting day in a by- Iection) Box A: Name of Candidate and Office Name of Candidate Last Name FirstName IMiddle Initial Samlal Mailing Address SuitelUnit No. I Street No. IStreet Name. I. Justin Cityrrown Province London ON Telephone No. (incl. area code) IFaxNo. Address Business IHome Name of office for which the candidate sought election Councilor Name of Municipality CityofLondon Ward Name or No. (if any) 7 IPostal Code m G Box B: Summary of Campaign Income and Expenses j 1. My spending limit (as issued by clerk) was i Surplus (or deficit) hom previous election 3. Total contributions received t!rom Scheouiel) 4. My total campaign expenses that were subject to the spending limit were (from Box C)

2 Box c: Statement of Campaign Period Income and Expenses From For Candidate yyyy Justin Samlal INCOME Candidate's surplus from immediately preceding election released by the ciet1< Contributions from candidate Contnbutions from spouse of candidate All other contributions Revenue from fund-raising functions not deemed a contribution (kom Schedule 2, Part III) Interest income Other (provide full details) =:: :1: Total Campaign Period Income 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) - Meetingshosted Nomination filing fee - Office expenses Phone and/or Internet Salaries and benefitslhonorariajprofessional fees - Signs Other (provide full details) 1.C~~~~~ ~~~~~~~ =.~f_,~L~;~-r~tf~~~~~~ ;G~l ~ ~ ftOO id) =:: f..-:> 1;Y " Subtotal = ~""1iliMI: 7.7 ") C2 Expenses Not Subject to Spending limit Accounting and audit Costs of fund-raising function (kom Schedule 2, Part IV) Expenses related to compliance audit Expenses retated to controverted elections Expenses related to recounts Voting day party f appreciation notices Expenses related to candidate's disability (provide details) 0 Ul? 'tot; {'..') 1 f-= i = f-= i = Other (provide full demils) ~ = r ~ ~ Subtotal = Total Campaign Pettod Expenses (C2, (C3) Excess (DefIciency) of Income over Expenses (C1, - (Ct, 9503P ( ) Page 20f 8

3 Box 0: Statement ofassets and liabilities as at May 25th,2011 Assets Cash Accounts receivable Value of inventory retained (from Schedule 4) Other (provide full details) ~ > ~ = Total Assets Uabilities and Excess (Deficiency) of Income OYer Expenses Accounts payable :I! Borrowings, overdraft other (provide full details) ~ = ~ Total Liabilities : ~~.5_2-1 : =Is r , r ~ = Is 0 Box E: Statement of Detennlnatlon of Surplus or DefIcit and DIsposition ofsurplus Part I - Detennlnation of Surplus or Deficit Amount of excess (deficiency) of income over expenses (from Box C) Deduct: Any deficit carried forward by the candidate from immediately preceding election if the offices are with respect to the same jurisdiction I-' O_.OO ~ E2 Surplus (or deficit) for the campaign period (E1) - (E2) = I-S--"l~"""''--_----j Deduct: Any refund of contributions to the candidate or spouse (only ifthere is a surplus) 0.00 Total Detennination = S E3 Part 11- Disposition ofsurplus 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, ~Justin S""aml......alL- ' a candidate in the municipality of _""Lo=D~d""on~,-"'O<..!D""tari= ""O'-- ' hereby dedare that to the best of my knowledge and belief that these financial statements and attached supporting schedules are true and COITed:. Declared before (clerk or commissioner) ~ in the on (yyyy/mmldd) C\hj U1 Wf\~\On :z0it )5 Date Filed in the Clerk's Office (yyyylmm/dd) SARAH AXFORD, a Commissio~er for taking Affidavits and Oatns. Mlddlese~ County. \Yhlle 8deputized Cler;( of The CorporatIon 9S03P (2010/01) of the CIt\' of London. Page 3me

4 Schedule 1 - Contributions Part I - Contribution Contribution from candidate - ~ ~ L:-~ ----.J Contribution from spouse Total from each single contributor totalling more than 100 include all ticket revenue where ticket price exceeds 100 include all goods and services where value exceeds 100" do not include contributions from candidate or spouse [ 5800 Total from each Single contributor totalling 100 or less include all ticket revenue where ticket price is 100 or less include all goods and services where value is 100 or less" do not include contributions from candidate or spouse "Note: Goods and services must also be reported as expenses in Box C Less: Contribution returned or payable to the contributor Contribution paid or payable to the clerk Total Amount of Contribution = Total contribution from anonymous sources Amount of contributions paid or payable to the clerk (1A) (18, = A ~"";;' , 18 Part 11- List of Contributions from Each Single Contributor Totalling More than 100 Table 1: Monetary contributions from Individuals other than candidate or spouse Name Add~ Amount P4 o Additional information is listed on separate supplementary attachment Total P ( ) Page 4 of 8

5 Table 2: Monetary contributions from unions or corporations Name (Legal and Canytng on Busl... As) Fonn&Build Slemko Investment Corp Address 1175 Frances Street London, ON NSW 2L9 129 Whiteacres Dr London, ON N6G 4E8 P...klentor Business Manager BmRoss Gerald Slemko Cheque Signatory Amount BmRoss 850 Gerald Slemko 200 Blueland Farms 560 Wellington Street London, ON N6A 3R4 500 ATI Technologies LID 350 Loncor holdings Inc 379 SlIooiogdale Road W London, ON N6G 5B9 750 Jim Chapman Inc 103 Elmwood Ave E London, ON N6C 1J4 Jim Chapman Jim Chapman 100 Wemham Wealth Managemen 431 Boler Road London, ON N6K 2KO TedWemham TedWemham 100 I]g Additional information is listed on separate supplementary attachment Table 3: Contributions In goods or services (Note: must also be reported as expenses in Box C) Name Address Goods or Services Total S 3200 Amount o Additional information is listed on separate supplementary attachment Total S Total Part II Contributions Is P (2Q1 01()1) Page 50f 8

6 Schedule 2 -~ljnd-raislng Function o Additional schedule for each event or activity held is/are listed on separate supplementary attachment(s) Date Description of event or activity YYYY DD FundraisingDinner Admission charge (per person) (may not exceed individual contribution limit) ,-,-I --"1'-'=00" l12a Ifadmission charge per person is not consistent. attach complete breakdown of all ticket sales. Number of tickets sold - ~3~3'-- '128 Part I - Ticket Revenue Lines: (2A) x (28) (include in Schedule 1) = Part II - Other Revenue Deemed A Contribution Provide full details (e.g. revenue from goods sold in excess of fair market value) Total Part II Revenue (Include in Schedule 1) = Part III - Other Revenue Not Deemed A Contribution Provide full details (e.g.. contributions of 10 or less; revenue from refreshment sold at cost) Total Part III Revenue (Include in Box C) = 1 Is Part IV - Expenses Related to FundoRaising Function Venue Event advertising Food and drink Entertainment Other (provide full details) l! Total Part IV Expenses (include in Box C) l! lrn.59 I 9503P ( ) PageS ate

7 Schedule 3 - Inventory of Campaign Goods and Materials (from Previous Campaign) Used in candidate's Campaign Description Date Acquired Suppler Unit Value (yyyy/mmldd) Quantity Total Value 1 Total Value of Inventory from Previous Campaign Used in Candidate's Campaign Schedule 4 -Inventory of campaign Goods and MaterIals at The End of Campaign Description ~pller UnitValue Quantity I Total Value Lawn Signs 2010/09/30 O'Dee Graphic Display 21 Total Value of Inventory of Campaign Goods and Materials ~. ' P (2010/0t) Page 7 of 6

8 Auditor's Report Municipal Elections Act, 1996 (Section 78) A candidate who has received contributions or incurred expenses in excess of must attach an auditors report. The report must be done in accordance with generally accepted auditing standards and must: set out the scope of the examination provide an opinion as to the completeness and accuracy of the financial statement and whether it is free of material misstatement Professional Designation of Auditor Municipality Date (yyyy/mmldd) Contact Person Last Name First Name Ucence No. Address SuitelUnit No. Street No. Street Name CitylTown Province Postal Code Telephone No. (ind. area code) Fax No. Address ext. 9503P ( ) Page 8 of 8

9 ~, Schedule 1. Table 2 Additional Info Name Edwards Door Systems Address Amount I PO Box Sarnia, ON N7T 7 J4 Parker, Prins, Lebano 1796 Courtwood Cres 50 Ottawa, ON K2C 285 The Hampton Group 580 Waterloo Street 100 London, ON N68 2P9 I