Pontario and Housing. ~,..o Q<s\.-o..l? ~ Financial Statement -.Auditor's Report Form4 Municipal Elections Act, 1996 (Section 78) ,,._...
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1 Ministry ofmunlclpataffairs Pontario and Housing lnstnctfons: Financial Statement -.Auditor's Report Form4 Municipal Elections Act, 1996 (Section 78) AU candidates must complete Boxes A and 8. Candidates who receive contnbulions or incur expenses beyond the nomination fee must complete Bo>ces C, 0, Schedule 1, and Schedule 2 as appropriate. Candidates who receive contributions or icicur 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 the cler1< who was responsible for the conduct ofthe election. yyyy For the campaign period from (day candidate flied nomination} 120 J L/ ~Primary filing reflecting finances to December 31 (or day after voting day in a by-election) 0 Supplementary filing including fuiances after December 31 (or day after voting day in a by-election) Box A: Name ofcandidate and Office Candidate's name as shown on the bahot Last Name /\! A/_ Given Name(s) ~ 01-I A) Ward name or no. (if any) Name of Municipality C,,/~ or Osh/.&w& Spending limit issued by@8(k $ 9'J>'.. 70 b,!ls: / 0 I did not accept any contributions or incur any expenses other than the nomination ree. (Complete BoK A and B only) Box B: Declaration I,...;:... ~~~_..._._...:...;=:::..>oao...j )..;::>h a ~<2- O..\. QS ~~...;..,,._...a a candidate in the municipality of,,_...,i...;a... = hereby declare 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 oommissioner) in the. c.0.\. oo (y,,y/mmldd) ~,..o Q<s\.-o..l? ~ ~ ;;l ~,.;J~ )c;- < ~na:u:ar:er1< or Commissioner Date Filed in the Clerk's Office (yyyy/mm/dd) 9503P ) 0 OuM11'1 Pitnerfor Ontario, 2013 Oiaponible en f~a Pa;e 1of8
2 Box C: Stat.ment of Campaign Income and Expenses LOAN Name of bank or recognized lending institution ~ ~ ~--- AmounIborrowed $ INCOME Total amount of all contributions (From line 1A in Schedule 1) + s/'/f/j'z So Refund of nomination f~ ing fee /00, OC? Sign deposit refund Revenue from fund-raising events not deemed a contnbution (From Part Ill of Schedule 2) Interest eamed by campaign bank account Other (provide full details) 1. ~ ~ it:;;. Total campaign Income (Do not Include loan) = $ 'l3'jp.5'0 C1 EXPENSES (Note: include the value orcontributions of goods and se1vices) Expenses sub}fft to spending limit Nomination filing fee Inventory from previous campaign used In this campaign (list details in Table 5 of Schedule 1) Advertising Brochures/flyers Signs (including sign deposit) Meetings hosted Office expenses incurred until voting day Phone a11dlor Internet expenses incurred until voling day Salaries, benefits, honoraria, professional fees incurred until voting day Bank charges incuned until vating day Interest charged on loan until voung day Other (provide tun details) ~ ~~f70 tii2tv~uar Total ExpttMH subject to spending lknlt = $ Expenses not subject to spending lfmlt Accounting and audit Cost of fund-01ising events/activities (fist delails in Part IV of Schedule 2) Voting day party/appreciation notice Office expenses incurred after voting day ::~i: ~r Phone and/or Internet expenses incurred after voting day Salaries, benefits, honoraria, profeuionai t'eea Incurred after voting day Sank charges incurred after voting day s q, 'ls.,- Jnterest charged on loan after voting day $ Expenses relaied to recount Expenses related to controverted election Expenses related to compliance audit Expenses related to candidate's disability (provide fuu deta~s) 1. ~~~---~~-~~~~~~---~~~-~~ Other (provide fuk details) 1. ~-~~-~~~~~~--~~~-~~~~~~~ ~ a Total Expenses not subject to spending llmlt = $ Total Campaign Expenaes {CZ+ C3) 9503P ( )
3 Box D: C lculatlon of Surplus or Deficit Excess (deficiency) of income over expenses (Income - Total Expenses) (C1 -C4) Eligible deficit carried forward by the candidate from the laat election Total (D1-02) Ifthere is a surplus, deduct any refund ofcandidate's or spouse's conlrilu1lons to the campaign Surplus (or deficit) for the campaign If line 03 shows a surplus, the amount must be paid in trust at the time the financial statements are filed, to the municipal cjeik who was reaponsble for the conduct orthe election. Amount of$ paid lo municipal clerk in the municipality of &503P (2013/11) Page3ol8
4 Schedule 1 Contributions Part I - Summary ofcontributions Contribution from candidate (include the value of inventory listed in Table 5) Contribution Crom spouae Total value of contri>utlons not exceeding $100 per contributor Include tld<et revenue, contributions in money, goods and services where the total contribution from a contributor Is $100 or less (do not indude contributions from candidate or spouse). Total value of contributions exceeding $100 per contributor (from line 1 B; list details In Tables 1-4) Include 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). Less: Contribution1 returned or payable to the contributor Contributions paid or payable to the clerk, Including contributions from anonymous sources exceeding $10 - $ Total Amount of Contribution (Record In Box C) Part I - Uat of Contributions from Each Single Contributor Totalling more than $100 $ 82/P'Z s-o = $~fi 7, S01A Table 1: Monetary contrlbuuona from lndlvlduala other than candidate or spouse N.me FullAddreu Amount$ IV/Cc tuit.. / 0/I/ (/;? 6 ~tove;as J'<oA-/.J l'j.s..vawrt I CJ;U /, ~/~ 3><9'? (}t:?, C) 'O P/J'f Sitt(He~~ //f/? ~te/j&'ot1~aje D~1t1e 1;..o~h'"Ac..JA, ~A)/, L /k t?6/.. 700, tjo,, 0 Additional information ia listed on separate supplementary attachment Total t./f)i"/,, /_)/") 9503P ( ) Pege4d8
5 Authorized Repl'Hentatlve Amount$ ~00 00 Z',4AJ r<ja..jfill;ey LJlivet,,tJ/!1t-tf3"".,.. e~a..r.,\jve.!'rneaj 7->o, oo 7.S-0, 0 CJ ~r.~ ~~~~~~-J:...:.!...:.._~ :~...,,.--l-!-.jj.:=~.1j4..~<l.f4.~~~~~~~-t-~~~~~~.s C/./A1At-:c1"A1.- 7soJ oo 50~,@0 Total Table 3: Contributions In goods or services from Individuals other than candidate orspouse (N ote: must a I so b e recor d e d as expenses 1n. B OX C) Name Full Address Description of Goods Value$ or Services - 0 Additional informabon is listed on separate supplementary attachment Total 9503? ( ) Page 5 of8
6 Table : ContrlbuUons In goods or services from corporations orunions (Note: must also be recorded as expenses In Box C) Name of Corporation FullAddNU President or Authortzed DescrfptiOn of Value$ (Legal and Carrying on Business Manager Representative Goods or Services Busineas As) O Additional infonnation is listed on separate supplementary attachment Total Part II ConbibuUons (Add Totals from Tables 1-4) (Record In Part I - Summary) Total...;.$ 1B Part Jtl - Inventory Tabfe 6: Inventory of Campaign Goods and Materials from Previous Campaign used In this Campaign (Note: value must be recorded as a contrfbuuon from the candidate and as an expense) Description Date Acquired Supplier Current M1rket QuanUty (yyyy/mm/dd) Value $ Total Value $ 0 Additional information la Uated on separate supplementary attachment Total 9S03P ( ) Page II of e
7 Schedule 2 - Fundralsing Events and Activities Fundralalng Event/Activity Complete a sepanit.e schedule for each event or activity held O Addilionat schedu!e(s) attached Date of event/activity (yyyy/mm/dd) Part 1-Ticket Revenue Admission charge (per person) (If there are a range of ticket prices, attach complete breakdown of all ticket sales) Number of tickets sold Total Ticket Revenue (2A X 28) (Include In Schedule 1) A x 28 = $ Part11-Other,.venue deemed a contribution (provide detal!s (e.g. revenue tram goods sold in excess of fair market value)) Total PartH Revenue (include In Schedule 1) = $ Part Ill - Other revenue not deemed e contribution (provide details (e.g. contributions of $10 or less; market value of goods or services sold)) _$ ~ 4. ~ Total Pert in Revenue (lnclud6 In Box C) = $ Part IV - Expenses related to fundrmlslng event oractivity (provide details) s Total Part IV Expenses (Include In Box C) ;: $ 9503P (2013/11) Page 7 af8
8 Auditor's Report Municipal Elections Ac~ 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 ofauditor Municipality IDate (yyyy/mm/dd) Contact Information last Name First Name licence Number Address Suite/Unit No. 'St~tNo. I Street Name City!Town Province Postal Code Telephone No. (including area code) Fax No. Address ext. The report must be done In accordance with generauy 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 0 Report is attached I I I Personal information, if any, collected on this form ia obtained under the authority of sections 78 and 95 of the Municipal Elections Act, Under section 88 or the Municipal Elections Aci, 1996 (and despite anything in the Municipal Freedom oflnfonnstion and Protection ofprivacy Act) documents and materials filed with or prepared by the cler1< or any other election official under the Municipsl Elections Act, 1996 are public records and, until their destruction, may be inspected by any parson at the cler1<'s office at a time when the office Is open. Campaign financlal statements shall also be made available by the clert< In an electronic fonnat free of charge upon request 9503P ( ) Pm; ao1a
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