Osha,Ja. :> Ontario and Housing
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1 ... I ):..:. Ministry r. :> Ontario and Housing Instructions: of Municipal Affairs Financial Statement - Auditor's Report Form4 Municipal Elections Act, 1996 (Section 78) All candidates must complete Boxes A and B. Candidates who receive contributions or incur expenses beyond the nomination fee must complete Boxes c. D, Schedule 1, and Schedule 2 as appropriate. Candidates who receive contributions or incur expenses in excess of $10,000 must also attach an Auditor's Report. All surplus funds (after any refund to the candidate or his or her spouse) shall be paid immediately over to lhe clerk who was responsible for the conduct of the election. yyyy MM DD YYYY MM DD For the campaign period from (day candidate filed nomination) I,;2 o I j- I o i I o ea I 0 1_ &._0_1_~._V_o._..l2'-'-rz~I it(primary filing rellecting finances to December 31 (or day after voting day rn a by-election) D Supplementary filing including finances after December 31 (or 451tt day after voting day in a by-election) Box A: Name of Candidate and Office Candidate's name as shown on the ballot Lest Name Given Name{s) Name of Municip lily Osha,Ja 0 I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and B only) Box B: Daclaratlon I,,._~i..µ..._, -'""'.., a candidate in the mun i~al ity of l.ill;.ll.'""'"'"4.o""""' ,hereby dedare that to the best of my knowledge and belief that these financial statements and attached supporting schedules are true and correct. Declared before (clerk or commissioner) inthe G ~ c}s D~~ C- on (yyyy/mmldd)~ ~'l ao\.;; ~S ignature of Candidate 950JP ( ) C Queen't> Printer for Ontario Dlspanible en fr.111~.s Page 1 of a
2 Box C: Statement ofcampaign Income and Expenses.. LOAN Name of bank or recognized lending institution c.!/ft Amount borrowed -$ ~...,...~~~~~~~~~~~ INCOME Total am~unt of all contributions (From line 1A in Schedule 1) Refund of nomination filing fee Sign deposit refund Revenue from fund-raising events not deemed a contribution (From Part Ill of Schedule 2) Interest earned by campaign bank account Other (provide full details) ~ ~ 1 Total Campaign Income (Do not Include loan) EXPENSES (Note: include the value of contributions of goods and services) Expenses subject to spending limit Nomination filing fee Inventory from previous campaign used In this campaign (list cteta~s in Table 5 of SChedule 1) Advertising Brochures/flyers Signs (including sign deposil) Meetings hosted Office expenses incurred until voting day Phone and/or lntemet expenses incurred until voting day Salaries, benefits. honoraria. professional fees incurred until voting day Bank charges incurred until voling day Interest charged on loan until voting day Other (provide full details) 1.,Bfick.-er, t (!(JC:S/sas 2 --~ ~--~ + 3. Total Expenses subject to spending Omit Expenses not subject to spending limit Accounting and audit Cost of fund-raising events/aclivilies (list details in Part IV of Schedule 2) Voling day party/appracialion notices Office expenses incurred after voting day Phone and/or Internet expenses incurred after voling day Salaries, benefits. honoraria, professional fees incurred after voting day Bank charges incurred after voting day Interest charged on loan after voting day Expenses related to recount Expenses related to controverted election Expenses related to compliance audit Expenses related to canclldate's disability (provide full details) 1 ---~-~-~---~----.,, ~ Other (provide full details) ~~- ~~~~~~~----~-- 3 ~75.oo +-s--=-,-uo.oo..er Ir -' "' $ $ = $ d; l f 0. Jo\ C2 + _$ _~t.l.1. + _$ ~1tv...J.~~P~rfi> ~ + -'--~... $ 3Jt.'>'...! 2. c:llm tato/.i" f'mt;l;;;a1..je.5 (wt:kr,ecf&e ~1&!) +...; ~~..;.:_jj~'"- s b... 0 r c: 3....: Total Expenses not subject to spending llmlt = $ 6d-1, 65 ~$ 'j_ ~J i..j.1. 8 Total Campaign Expens" (C2 + C3) ~ I ~ 9S03P (2013/H) Page 2 ol a
3 Box D: Calculation of Surplus or Deficit Excess (deficiency) of income over expenses (Income - Total Expenses) (C1 -C4) 6~ Eligible deficit carried forward by the candidate from the last election - $ J ~ 02 Total (01-02) Ifthere Is a surplus, deduct any refund of candidate's or = $ J; J.1.._tl spouse's contributions to the campaign - $ ~)Go.>O Surplus (or deficit) for the campaign.. $ (_~ 81J~Sh) If line 03 shows a surplus, the amount must be paid in trust, at the time the financial statements are filed, to the municipal cler1< who was responsible for the conduct of the election. Amount of$ paid to municipal clerk in the municipality of ~~~~~~~~~ -~~~~~~~~~~~~~~~~~~ &5<13P(2013/11) Page 3 ol 8
4 Schedule 1 - Contributions Part I - Summary of Contributions ConbibuUon from candidate (include the value of inventory lisled in Table 5).J.,.po. co Contribution from spouse +-$, ,.,.- J:? > Total value of contnbutions not exceeding $100 per c.ontributor!nclude ticket revenue, contributions in money. goods and services where the total contribution from a contributor is $100 or less (do not include contributions from candidate or spou.se). '(p ,o Total value of contnbutions exceeding $100 per contributor (from line 18; list detaus in Tables 1-4) lnelude ticket revenue, contributions In money, goods and services where the total contribution from a contributor exceeds $100 (do not include contributions from candidate or spouse). 1 ;)._<)., ~ less: Conlnbulions retu~d or payable to the contributor $ Contributions paid or payable to the clerk, including contributions from anonymous sources exceeding $10 $ Total Amount of Contributions (Record In Box Ct = =$====-3-~?J.cJi) IA Part II - List ofcontributions from Each Single Contributor Totalling more than $100 Table 1: Monetary contributions from Individuals other than candidate or spouse Name Full Address ' I Amount$ y I 0 Additional information is listed on separate supplementary attachment Total r t2r"' 9503P (2013/11) Page" of 8
5 Table 2: Monetary contributions from con>oratlons or unions Name (legal and Carrying on Full AddreH President or Authorized Amount$ Business As) Business Manager 0 Representative -- I t.jj-) pji14",,,.. J!UlA-~ A~ L(5 tj Ali~ ~l1fc.~g~ t-1-c. '> fl joo.cu Cl AF>-;,;R, ~ ~ OSH-~fl- 1-1 :r9i- '{ IY\lktlo...A\.-Q Nl~Oo~ ~1-\i\- J...A~ r Ah...,\ If')...q.,_e,,ztJr s 1. 0St{~t'- Lf H "/K3 --:(""" -l1w\.. 11 I fte6;vt'j'\.,.j,::,-elf,ec.alla...i /00. oo O Additional information is listed on separate supplementary attachment Total If 600 <.)~ Table 3: Contributions In goods orservices from Individuals other than candidate or spouse (Note; must also be recorded as expanses In Box C) Name Full Address Description of Goods Value$ or Services rj1ru(\ J...Jc.Vt kl\-. L/if'if{, 1-IH ffjj 1 f",c_t~ /<fj ~., /J;/oroC[q\F1Hy 4 t)s-- u~ 0 Addibonal information is listed on separate supplementary attachment Total.J/ I :J.'), ex:> 9503P ( ) Pape 5018
6 Table 4: Contributions In goods or services from corporations or unions (Note: must also be recorded as expenses In Box C) Name of Corporation Full Address President or Authorized Description of Value$ {legal and Carrying on Business Manager Representative Goods or Services Business As) ~ i D Additional infonnalion is listed on separate supplementary attachment Total Total Part II Contributions (Add Totals from Tables 1-4) (Record In Part I - Summary) $.,,el' 18 Part Ill - Inventory Table 5: Inventory ofcampaign Goods and Materials from Previous Campaign used In this Campaign (Note: value must be recorded as a contribution from the candidate and as an expena.) Description Date Acquired (yyyy/mm/dd) Supplier Current Market Value S Quantity Total Value$ ~ O Additional information is listed on separate supplementary attachment Total ~ 9503P ( ) Page 6 Df B
7 Schedule 2 - Fundralslng Events and Activities Fundralslng Event/Activity Complete a separate schedule foreach event oracuvlty held D Additional schedule(s) attached Description of fundraising evenuacttvity Date ofevenvactivity (yyyy/mmfdd) Part I - Ticket Revenue Admission charge (per person) (If there are a range of ticket prices, attach complete breakdown of all ticket sales) Number oftickets sold Total Ticket Revenue (2.A X 28) (Include In Schedule 1) + x $ 2A 28 = $.fer Part 11- Other revenue deemed a contribution (provide details (e.g. revenue from goods sold in excess of fair market value)) Total Part II Revenue (Include In Schedule 1) = $ + $ $ $ Put Ill- Other revenue not deemed a contribution (provide details (e.g. contributions of $10 or less; market value of goods or services sold)) Total Part Ill Revenue (Include In Box C) $ Part IV - Expenses related to fundralslng event or activity (provide details) Total Part IV Expenses (Include In Box C) = $ d 9503P ( ) Page 7 018
8 Auditor's Report Municipal Elections Act, 1996 (Section 78) A candidate who has received contributions or incurred expenses in excess of $10,000 must attach an auditor's report. Professional Designation of Auditor Municipality I Date (yyyy/mm/dd) Contact Information Last Name IFirst Name Ilicence Number I Address SuitefUnit No. Street No. Street Name I Cilyffown Province Postal Code Telephone No. (induding area code) Fax No. Address ext. The report must be done in acc:ordance with generally accepted auditing standards and must set out the scope of the examination provide an opinion as to the completeness and accuracy ofthe financial statement and whether it is free of material misstatement D Report Is attached Personal information, if any. collected on this form is obtained under the authority of sections 78 and 95 ofthe Municipal Elections Act, Under section 88 or the Munlcipaf Efeclions Act, 1996 (and despite anything in the Municipal Freedom of Information and Proteclion ofprivacy Act) documents and materials filed with or prepared by the cletk or any other election official under the Municipal Elections Act, 1996 are public records and, until their destruction, may be inspected by any person at the clerk's office at a time when the office is open. Campaign financial statements shall also be made available by the clerk in an electronic fonnat free of charge upon request 9503P (2013/11) Page 8 of 8
Financial Statement - Auditor's Report Candidate - Form 4
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